pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	part_d_model_demo	part_d_enhncd_cvrg_demo	mrx_tier_label_list	mrx_tier_benefit_type	mrx_tier_drug_type	mrx_tier_includes	mrx_tier_cstshr_struct_type	mrx_tier_id	mrx_tier_type_id	mrx_tier_locat_rstd	mrx_tier_locat_rsplt	mrx_tier_locat_oon	mrx_tier_locat_mostd	mrx_tier_locat_mosplt	mrx_tier_locat_ltc	mrx_tier_rstd_1m_num	mrx_tier_rstd_2m_num	mrx_tier_rstd_3m_num	mrx_tier_rsplt_1m_num	mrx_tier_rsplt_2m_num	mrx_tier_rsplt_3m_num	mrx_tier_extd_days_yn	mrx_tier_extd_first_fill	mrx_tier_mostd_1m_num	mrx_tier_mostd_2m_num	mrx_tier_mostd_3m_num	mrx_tier_mosplt_1m_num	mrx_tier_mosplt_2m_num	mrx_tier_mosplt_3m_num	mrx_tier_oonp_1m_num	mrx_tier_oonp_othnumn	mrx_tier_ltcp_1m	mrx_tier_rstd_copay_1m	mrx_tier_rstd_copay_2m	mrx_tier_rstd_copay_3m	mrx_tier_rstd_coins_avg_1m	mrx_tier_rstd_coins_1m	mrx_tier_rstd_coins_2m	mrx_tier_rstd_coins_3m	mrx_tier_rsstd_copay_1m	mrx_tier_rsstd_copay_2m	mrx_tier_rsstd_copay_3m	mrx_tier_rsstd_coins_avg_1m	mrx_tier_rsstd_coins_1m	mrx_tier_rsstd_coins_2m	mrx_tier_rsstd_coins_3m	mrx_tier_rspfd_copay_1m	mrx_tier_rspfd_copay_2m	mrx_tier_rspfd_copay_3m	mrx_tier_rspfd_coins_avg_1m	mrx_tier_rspfd_coins_1m	mrx_tier_rspfd_coins_2m	mrx_tier_rspfd_coins_3m	mrx_tier_mostd_copay_1m	mrx_tier_mostd_copay_2m	mrx_tier_mostd_copay_3m	mrx_tier_mostd_coins_1m	mrx_tier_mostd_coins_2m	mrx_tier_mostd_coins_3m	mrx_tier_mosstd_copay_1m	mrx_tier_mosstd_copay_2m	mrx_tier_mosstd_copay_3m	mrx_tier_mosstd_coins_1m	mrx_tier_mosstd_coins_2m	mrx_tier_mosstd_coins_3m	mrx_tier_mospfd_copay_1m	mrx_tier_mospfd_copay_2m	mrx_tier_mospfd_copay_3m	mrx_tier_mospfd_coins_1m	mrx_tier_mospfd_coins_2m	mrx_tier_mospfd_coins_3m	mrx_tier_oonp_copay_1m	mrx_tier_oonp_copay_othnum	mrx_tier_oonp_coins_1m	mrx_tier_oonp_coins_othnum	mrx_tier_ltcp_copay_1m	mrx_tier_ltcp_coins_1m	mrx_tier_rstd_copay_daily	mrx_tier_rsstd_copay_daily	mrx_tier_rspfd_copay_daily	mrx_tier_mostd_copay_daily	mrx_tier_mosstd_copay_daily	mrx_tier_mospfd_copay_daily	mrx_tier_ltcp_copay_daily	mrx_tier_form_model_desc	mrx_tier_includes_mmp	mrx_tier_copay_amt_rstd_mmpmin	mrx_tier_copay_amt_rstd_mmpmax	mrx_tier_copay_amt_oon_mmpmin	mrx_tier_copay_amt_oon_mmpmax	mrx_tier_copay_amt_mstd_mmpmin	mrx_tier_copay_amt_mstd_mmpmax	mrx_tier_copay_amt_ltc_mmpmin	mrx_tier_copay_amt_ltc_mmpmax	mrx_tier_gap_cost_share	mrx_tier_gap_part_drugs	mrx_tier_gap_part_includes	mrx_tier_ira_rstd_copay_1m	mrx_tier_ira_rstd_copay_2m	mrx_tier_ira_rstd_copay_3m	mrx_tier_ira_rspfd_copay_1m	mrx_tier_ira_rspfd_copay_2m	mrx_tier_ira_rspfd_copay_3m	mrx_tier_ira_mostd_copay_1m	mrx_tier_ira_mostd_copay_2m	mrx_tier_ira_mostd_copay_3m	mrx_tier_ira_mopfd_copay_1m	mrx_tier_ira_mopfd_copay_2m	mrx_tier_ira_mopfd_copay_3m	mrx_tier_ira_oonp_copay_1m	mrx_tier_ira_oonp_copay_othnum	mrx_tier_ira_ltcp_copay_1m
H0022	001	0	1	48	05	H0022_001_0	13			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0022	001	0	1	48	05	H0022_001_0	13			Brand Drugs	4	10		2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0022	001	0	1	48	05	H0022_001_0	13			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0028	014	0	1	01	01	H0028_014_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	014	0	1	01	01	H0028_014_0	8			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	014	0	1	01	01	H0028_014_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	014	0	1	01	01	H0028_014_0	8			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	014	0	1	01	01	H0028_014_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	014	0	1	01	01	H0028_014_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	014	0	1	01	01	H0028_014_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	016	0	1	02	01	H0028_016_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H0028	016	0	1	02	01	H0028_016_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	11.00		33.00																									20.00		60.00				11.00		0.00				11.00				11.00		0.37				0.67	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00		33.00				20.00		60.00	11.00		0.00	11.00		11.00
H0028	016	0	1	02	01	H0028_016_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	016	0	1	02	01	H0028_016_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	016	0	1	02	01	H0028_016_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	017	0	1	01	01	H0028_017_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H0028	017	0	1	01	01	H0028_017_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	11.00		33.00																									20.00		60.00				11.00		0.00				11.00				11.00		0.37				0.67	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00		33.00				20.00		60.00	11.00		0.00	11.00		11.00
H0028	017	0	1	01	01	H0028_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	017	0	1	01	01	H0028_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	017	0	1	01	01	H0028_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	019	0	1	01	01	H0028_019_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	019	0	1	01	01	H0028_019_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	019	0	1	01	01	H0028_019_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	019	0	1	01	01	H0028_019_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	019	0	1	01	01	H0028_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	019	0	1	01	01	H0028_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	019	0	1	01	01	H0028_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	021	0	1	01	01	H0028_021_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H0028	021	0	1	01	01	H0028_021_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H0028	021	0	1	01	01	H0028_021_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	42.00		126.00																									47.00		141.00				42.00		84.00				42.00				42.00		1.40				1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		84.00	35.00		35.00
H0028	021	0	1	01	01	H0028_021_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		190.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	021	0	1	01	01	H0028_021_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	023	0	1	01	01	H0028_023_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H0028	023	0	1	01	01	H0028_023_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H0028	023	0	1	01	01	H0028_023_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	023	0	1	01	01	H0028_023_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	023	0	1	01	01	H0028_023_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	024	0	1	01	01	H0028_024_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	024	0	1	01	01	H0028_024_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	024	0	1	01	01	H0028_024_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H0028	024	0	1	01	01	H0028_024_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	024	0	1	01	01	H0028_024_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	024	0	1	01	01	H0028_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	024	0	1	01	01	H0028_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	025	1	1	01	01	H0028_025_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	025	1	1	01	01	H0028_025_1	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	025	1	1	01	01	H0028_025_1	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H0028	025	1	1	01	01	H0028_025_1	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	025	1	1	01	01	H0028_025_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	025	1	1	01	01	H0028_025_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		190.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	025	1	1	01	01	H0028_025_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	025	2	1	01	01	H0028_025_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	025	2	1	01	01	H0028_025_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	025	2	1	01	01	H0028_025_2	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H0028	025	2	1	01	01	H0028_025_2	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	025	2	1	01	01	H0028_025_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	025	2	1	01	01	H0028_025_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		190.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	025	2	1	01	01	H0028_025_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	027	0	1	01	01	H0028_027_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H0028	027	0	1	01	01	H0028_027_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H0028	027	0	1	01	01	H0028_027_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	027	0	1	01	01	H0028_027_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	027	0	1	01	01	H0028_027_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	028	0	1	01	01	H0028_028_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H0028	028	0	1	01	01	H0028_028_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H0028	028	0	1	01	01	H0028_028_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	028	0	1	01	01	H0028_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	028	0	1	01	01	H0028_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	029	0	1	01	01	H0028_029_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	029	0	1	01	01	H0028_029_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	029	0	1	01	01	H0028_029_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	029	0	1	01	01	H0028_029_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	029	0	1	01	01	H0028_029_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	029	0	1	01	01	H0028_029_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	029	0	1	01	01	H0028_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	030	0	1	01	01	H0028_030_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	030	0	1	01	01	H0028_030_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	030	0	1	01	01	H0028_030_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	030	0	1	01	01	H0028_030_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	030	0	1	01	01	H0028_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	42.00		126.00																									47.00		141.00				42.00		116.00				42.00				42.00		1.40				1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	030	0	1	01	01	H0028_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	030	0	1	01	01	H0028_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	035	0	1	01	01	H0028_035_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	035	0	1	01	01	H0028_035_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	035	0	1	01	01	H0028_035_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	035	0	1	01	01	H0028_035_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	035	0	1	01	01	H0028_035_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	037	0	1	01	01	H0028_037_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	037	0	1	01	01	H0028_037_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	037	0	1	01	01	H0028_037_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	037	0	1	01	01	H0028_037_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	037	0	1	01	01	H0028_037_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	037	0	1	01	01	H0028_037_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	037	0	1	01	01	H0028_037_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	039	0	1	01	01	H0028_039_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	039	0	1	01	01	H0028_039_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	039	0	1	01	01	H0028_039_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	039	0	1	01	01	H0028_039_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	039	0	1	01	01	H0028_039_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	039	0	1	01	01	H0028_039_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	039	0	1	01	01	H0028_039_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	041	0	1	01	01	H0028_041_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	041	0	1	01	01	H0028_041_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	041	0	1	01	01	H0028_041_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	041	0	1	01	01	H0028_041_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	041	0	1	01	01	H0028_041_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	041	0	1	01	01	H0028_041_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	041	0	1	01	01	H0028_041_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	042	0	1	01	01	H0028_042_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	042	0	1	01	01	H0028_042_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	042	0	1	01	01	H0028_042_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	042	0	1	01	01	H0028_042_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	042	0	1	01	01	H0028_042_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	042	0	1	01	01	H0028_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	042	0	1	01	01	H0028_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	043	1	1	01	01	H0028_043_1	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	043	1	1	01	01	H0028_043_1	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	043	1	1	01	01	H0028_043_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	043	1	1	01	01	H0028_043_1	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	043	1	1	01	01	H0028_043_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	043	1	1	01	01	H0028_043_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	043	1	1	01	01	H0028_043_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	043	2	1	01	01	H0028_043_2	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	043	2	1	01	01	H0028_043_2	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	043	2	1	01	01	H0028_043_2	8			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	043	2	1	01	01	H0028_043_2	8			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	043	2	1	01	01	H0028_043_2	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	043	2	1	01	01	H0028_043_2	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	043	2	1	01	01	H0028_043_2	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	046	0	1	01	01	H0028_046_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	046	0	1	01	01	H0028_046_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	046	0	1	01	01	H0028_046_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	046	0	1	01	01	H0028_046_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	046	0	1	01	01	H0028_046_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	046	0	1	01	01	H0028_046_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	046	0	1	01	01	H0028_046_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	047	0	1	01	01	H0028_047_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H0028	047	0	1	01	01	H0028_047_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H0028	047	0	1	01	01	H0028_047_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	047	0	1	01	01	H0028_047_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	047	0	1	01	01	H0028_047_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	048	1	1	01	01	H0028_048_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	048	1	1	01	01	H0028_048_1	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	048	1	1	01	01	H0028_048_1	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	048	1	1	01	01	H0028_048_1	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	048	1	1	01	01	H0028_048_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H0028	048	1	1	01	01	H0028_048_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	048	1	1	01	01	H0028_048_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	048	2	1	01	01	H0028_048_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	048	2	1	01	01	H0028_048_2	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	048	2	1	01	01	H0028_048_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	048	2	1	01	01	H0028_048_2	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	048	2	1	01	01	H0028_048_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H0028	048	2	1	01	01	H0028_048_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	048	2	1	01	01	H0028_048_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	050	0	1	01	01	H0028_050_0	10			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	050	0	1	01	01	H0028_050_0	10			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	050	0	1	01	01	H0028_050_0	10			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	050	0	1	01	01	H0028_050_0	10			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	050	0	1	01	01	H0028_050_0	10			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	050	0	1	01	01	H0028_050_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	050	0	1	01	01	H0028_050_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H0028	050	0	1	01	01	H0028_050_0	10			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H0028	051	0	1	01	01	H0028_051_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	051	0	1	01	01	H0028_051_0	8			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	051	0	1	01	01	H0028_051_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	051	0	1	01	01	H0028_051_0	8			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	051	0	1	01	01	H0028_051_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	051	0	1	01	01	H0028_051_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	051	0	1	01	01	H0028_051_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H0028	051	0	1	01	01	H0028_051_0	8			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H0028	052	0	1	01	01	H0028_052_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	052	0	1	01	01	H0028_052_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	052	0	1	01	01	H0028_052_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	052	0	1	01	01	H0028_052_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	052	0	1	01	01	H0028_052_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	052	0	1	01	01	H0028_052_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	052	0	1	01	01	H0028_052_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	053	1	1	01	01	H0028_053_1	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	053	1	1	01	01	H0028_053_1	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	053	1	1	01	01	H0028_053_1	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	053	1	1	01	01	H0028_053_1	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	053	1	1	01	01	H0028_053_1	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	053	1	1	01	01	H0028_053_1	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	053	1	1	01	01	H0028_053_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	053	3	1	01	01	H0028_053_3	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	053	3	1	01	01	H0028_053_3	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	053	3	1	01	01	H0028_053_3	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	053	3	1	01	01	H0028_053_3	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	053	3	1	01	01	H0028_053_3	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	053	3	1	01	01	H0028_053_3	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	053	3	1	01	01	H0028_053_3	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	053	4	1	01	01	H0028_053_4	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	053	4	1	01	01	H0028_053_4	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	053	4	1	01	01	H0028_053_4	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	053	4	1	01	01	H0028_053_4	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	053	4	1	01	01	H0028_053_4	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	053	4	1	01	01	H0028_053_4	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	053	4	1	01	01	H0028_053_4	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	054	1	1	02	01	H0028_054_1	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	054	1	1	02	01	H0028_054_1	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	054	1	1	02	01	H0028_054_1	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	054	1	1	02	01	H0028_054_1	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	054	1	1	02	01	H0028_054_1	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	054	1	1	02	01	H0028_054_1	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	054	1	1	02	01	H0028_054_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	054	2	1	02	01	H0028_054_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	054	2	1	02	01	H0028_054_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	054	2	1	02	01	H0028_054_2	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	054	2	1	02	01	H0028_054_2	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0028	054	2	1	02	01	H0028_054_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	054	2	1	02	01	H0028_054_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	054	2	1	02	01	H0028_054_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	055	0	1	02	01	H0028_055_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	055	0	1	02	01	H0028_055_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	055	0	1	02	01	H0028_055_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	055	0	1	02	01	H0028_055_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	055	0	1	02	01	H0028_055_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	055	0	1	02	01	H0028_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	055	0	1	02	01	H0028_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H0028	055	0	1	02	01	H0028_055_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H0028	056	0	1	02	01	H0028_056_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	056	0	1	02	01	H0028_056_0	8			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	056	0	1	02	01	H0028_056_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	056	0	1	02	01	H0028_056_0	8			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	056	0	1	02	01	H0028_056_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	056	0	1	02	01	H0028_056_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	056	0	1	02	01	H0028_056_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H0028	056	0	1	02	01	H0028_056_0	8			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H0028	057	0	1	01	01	H0028_057_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	057	0	1	01	01	H0028_057_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	057	0	1	01	01	H0028_057_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	057	0	1	01	01	H0028_057_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0028	057	0	1	01	01	H0028_057_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	057	0	1	01	01	H0028_057_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	057	0	1	01	01	H0028_057_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H0028	057	0	1	01	01	H0028_057_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H0028	059	0	1	01	01	H0028_059_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	059	0	1	01	01	H0028_059_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	059	0	1	01	01	H0028_059_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	059	0	1	01	01	H0028_059_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	059	0	1	01	01	H0028_059_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	059	0	1	01	01	H0028_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	059	0	1	01	01	H0028_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	060	0	1	01	01	H0028_060_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	060	0	1	01	01	H0028_060_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	060	0	1	01	01	H0028_060_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0028	060	0	1	01	01	H0028_060_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0028	060	0	1	01	01	H0028_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0028	060	0	1	01	01	H0028_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	060	0	1	01	01	H0028_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	062	0	1	01	01	H0028_062_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	062	0	1	01	01	H0028_062_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	062	0	1	01	01	H0028_062_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H0028	062	0	1	01	01	H0028_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	062	0	1	01	01	H0028_062_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0028	063	0	1	01	01	H0028_063_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0028	063	0	1	01	01	H0028_063_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0028	063	0	1	01	01	H0028_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H0028	063	0	1	01	01	H0028_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0028	063	0	1	01	01	H0028_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0074	001	0	1	04	01	H0074_001_0	21			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0074	001	0	1	04	01	H0074_001_0	21			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0074	001	0	1	04	01	H0074_001_0	21			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0074	001	0	1	04	01	H0074_001_0	21			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0074	001	0	1	04	01	H0074_001_0	21			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.08	50	50	50				83.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0074	001	0	1	04	01	H0074_001_0	21			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0074	001	0	1	04	01	H0074_001_0	21			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0074	001	0	1	04	01	H0074_001_0	21			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0088	002	0	1	04	01	H0088_002_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0088	002	0	1	04	01	H0088_002_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0088	002	0	1	04	01	H0088_002_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0088	002	0	1	04	01	H0088_002_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.02	50	50	50				98.02	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0088	002	0	1	04	01	H0088_002_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0088	002	0	1	04	01	H0088_002_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0088	002	0	1	04	01	H0088_002_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0088	003	0	1	04	01	H0088_003_0	21			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0088	003	0	1	04	01	H0088_003_0	21			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0088	003	0	1	04	01	H0088_003_0	21			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0088	003	0	1	04	01	H0088_003_0	21			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.31	48	48	48				98.31	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0088	003	0	1	04	01	H0088_003_0	21			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0088	003	0	1	04	01	H0088_003_0	21			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0088	003	0	1	04	01	H0088_003_0	21			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0104	012	0	1	04	01	H0104_012_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					4.00		8.00											7.00		14.00				0.00		0.00				11.00				11.00			0.36	0.13		0.23	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	4.00		8.00	7.00		14.00	0.00		0.00	11.00		11.00
H0104	012	0	1	04	01	H0104_012_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								20.00		60.00					13.00		26.00											20.00		40.00				13.00		26.00				20.00				20.00			0.66	0.43		0.66	0.43	0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00		60.00	13.00		26.00	20.00		40.00	13.00		26.00	20.00		20.00
H0104	012	0	1	04	01	H0104_012_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H0104	012	0	1	04	01	H0104_012_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											94.20	33		33				78.50	28		28										33		33				28		28			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H0104	012	0	1	04	01	H0104_012_0	5			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0104	012	0	1	04	01	H0104_012_0	5			Select Care Drugs	4	01	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											0.00		0.00				0.00		0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0104	012	0	1	04	01	H0104_012_0	5			Select Care Drugs	4	01	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											0.00		0.00				0.00		0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0104	014	0	1	04	01	H0104_014_0	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					4.00		8.00											7.00		14.00				0.00		0.00				11.00				11.00			0.36	0.13		0.23	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	4.00		8.00	7.00		14.00	0.00		0.00	11.00		11.00
H0104	014	0	1	04	01	H0104_014_0	4			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								20.00		60.00					13.00		26.00											20.00		40.00				13.00		26.00				20.00				20.00			0.66	0.43		0.66	0.43	0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00		60.00	13.00		26.00	20.00		40.00	13.00		26.00	20.00		20.00
H0104	014	0	1	04	01	H0104_014_0	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H0104	014	0	1	04	01	H0104_014_0	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											99.90	33		33				80.42	28		28										33		33				28		28			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H0104	014	0	1	04	01	H0104_014_0	4			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0104	014	0	1	04	01	H0104_014_0	4			Select Care Drugs	4	01	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											0.00		0.00				0.00		0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0104	014	0	1	04	01	H0104_014_0	4			Select Care Drugs	4	01	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											0.00		0.00				0.00		0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0104	015	0	1	04	01	H0104_015_0	3			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					3.00		6.00											7.00		14.00				0.00		0.00				10.00				10.00			0.33	0.10		0.23	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	3.00		6.00	7.00		14.00	0.00		0.00	10.00		10.00
H0104	015	0	1	04	01	H0104_015_0	3			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		45.00					8.00		16.00											15.00		30.00				8.00		16.00				15.00				15.00			0.50	0.27		0.50	0.27	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00		45.00	8.00		16.00	15.00		30.00	8.00		16.00	15.00		15.00
H0104	015	0	1	04	01	H0104_015_0	3			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H0104	015	0	1	04	01	H0104_015_0	3			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											98.48	34		34				77.17	29		29										34		34				29		29			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H0104	015	0	1	04	01	H0104_015_0	3			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0104	015	0	1	04	01	H0104_015_0	3			Select Care Drugs	4	01	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											0.00		0.00				0.00		0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0104	015	0	1	04	01	H0104_015_0	3			Select Care Drugs	4	01	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											0.00		0.00				0.00		0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0107	003	0	1	04	01	H0107_003_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H0107	003	0	1	04	01	H0107_003_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0107	003	0	1	04	01	H0107_003_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H0107	003	0	1	04	01	H0107_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H0107	003	0	1	04	01	H0107_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	003	0	1	04	01	H0107_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0107	004	0	1	04	01	H0107_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H0107	004	0	1	04	01	H0107_004_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0107	004	0	1	04	01	H0107_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H0107	004	0	1	04	01	H0107_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H0107	004	0	1	04	01	H0107_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	004	0	1	04	01	H0107_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0107	005	0	1	04	01	H0107_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H0107	005	0	1	04	01	H0107_005_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H0107	005	0	1	04	01	H0107_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	005	0	1	04	01	H0107_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	005	0	1	04	01	H0107_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0107	006	0	1	04	01	H0107_006_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H0107	006	0	1	04	01	H0107_006_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H0107	006	0	1	04	01	H0107_006_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	006	0	1	04	01	H0107_006_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	006	0	1	04	01	H0107_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0107	007	0	1	04	01	H0107_007_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H0107	007	0	1	04	01	H0107_007_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H0107	007	0	1	04	01	H0107_007_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	007	0	1	04	01	H0107_007_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	007	0	1	04	01	H0107_007_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0107	010	0	1	04	01	H0107_010_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H0107	010	0	1	04	01	H0107_010_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H0107	010	0	1	04	01	H0107_010_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	010	0	1	04	01	H0107_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0107	010	0	1	04	01	H0107_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0111	001	0	1	04	01	H0111_001_0	20			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0111	001	0	1	04	01	H0111_001_0	20			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0111	001	0	1	04	01	H0111_001_0	20			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0111	001	0	1	04	01	H0111_001_0	20			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.21	50	50	50				98.21	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0111	001	0	1	04	01	H0111_001_0	20			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0111	001	0	1	04	01	H0111_001_0	20			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0111	001	0	1	04	01	H0111_001_0	20			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0137	001	0	1	48	05	H0137_001_0	8			Preferred Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31																																														0.00			0.00			0.00	Preferred Generic Drugs, Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0137	001	0	1	48	05	H0137_001_0	8			Generic Drugs	4	01		2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31																																														0.00			0.00			0.00	Preferred Generic Drugs, Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0137	001	0	1	48	05	H0137_001_0	8			Preferred Brand Drugs	4	10		2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31																																														0.00			0.00			0.00	Preferred Generic Drugs, Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0137	001	0	1	48	05	H0137_001_0	8			Non-Preferred Brand Drugs	4	11		2	4	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31																																														0.00			0.00			0.00	Preferred Generic Drugs, Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0137	001	0	1	48	05	H0137_001_0	8			Non-Medicare Rx/OTC Drugs	4	11		2	5	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31																																														0.00			0.00			0.00	Preferred Generic Drugs, Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0154	011	0	1	01	01	H0154_011_0	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									4.00	8.00	12.00				0.00	0.00	0.00				0.00				0.00		0.00				0.13	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				4.00	8.00	12.00	0.00	0.00	0.00	0.00		0.00
H0154	011	0	1	01	01	H0154_011_0	4			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	20.00																									8.00	16.00	24.00				7.00	13.50	16.00				8.00				8.00		0.27				0.27	0.23	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	20.00				8.00	16.00	24.00	7.00	13.50	16.00	8.00		8.00
H0154	011	0	1	01	01	H0154_011_0	4			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	117.50																									47.00	94.00	141.00				39.50	78.50	94.00				47.00				47.00		1.57				1.57	1.32	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0154	011	0	1	01	01	H0154_011_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	250.00																									100.00	200.00	300.00				85.00	170.00	200.00				100.00				100.00		3.33				3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0154	011	0	1	01	01	H0154_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				1.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	012	0	1	01	01	H0154_012_0	4		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H0154	012	0	1	01	01	H0154_012_0	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0154	012	0	1	01	01	H0154_012_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0154	012	0	1	01	01	H0154_012_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0154	012	0	1	01	01	H0154_012_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	015	1	1	01	01	H0154_015_1	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									4.00	8.00	12.00				0.00	0.00	0.00				0.00				0.00		0.00				0.13	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				4.00	8.00	12.00	0.00	0.00	0.00	0.00		0.00
H0154	015	1	1	01	01	H0154_015_1	4			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	12.00	24.00	30.00																									12.00	24.00	36.00				10.00	20.00	24.00				12.00				12.00		0.40				0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	30.00				12.00	24.00	36.00	10.00	20.00	24.00	12.00		12.00
H0154	015	1	1	01	01	H0154_015_1	4			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	117.50																									47.00	94.00	141.00				39.50	78.50	94.00				47.00				47.00		1.57				1.57	1.32	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0154	015	1	1	01	01	H0154_015_1	4			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	250.00																									100.00	200.00	300.00				85.00	170.00	200.00				100.00				100.00		3.33				3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0154	015	1	1	01	01	H0154_015_1	4			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				1.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	015	2	1	01	01	H0154_015_2	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									4.00	8.00	12.00				0.00	0.00	0.00				0.00				0.00		0.00				0.13	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				4.00	8.00	12.00	0.00	0.00	0.00	0.00		0.00
H0154	015	2	1	01	01	H0154_015_2	4			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	12.00	24.00	30.00																									12.00	24.00	36.00				10.00	20.00	24.00				12.00				12.00		0.40				0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	30.00				12.00	24.00	36.00	10.00	20.00	24.00	12.00		12.00
H0154	015	2	1	01	01	H0154_015_2	4			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	117.50																									47.00	94.00	141.00				39.50	78.50	94.00				47.00				47.00		1.57				1.57	1.32	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0154	015	2	1	01	01	H0154_015_2	4			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	250.00																									100.00	200.00	300.00				85.00	170.00	200.00				100.00				100.00		3.33				3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0154	015	2	1	01	01	H0154_015_2	4			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				1.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	016	0	1	01	01	H0154_016_0	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									4.00	8.00	12.00				0.00	0.00	0.00				0.00				0.00		0.00				0.13	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				4.00	8.00	12.00	0.00	0.00	0.00	0.00		0.00
H0154	016	0	1	01	01	H0154_016_0	4			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	12.00	24.00	30.00																									12.00	24.00	36.00				10.00	20.00	24.00				12.00				12.00		0.40				0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	30.00				12.00	24.00	36.00	10.00	20.00	24.00	12.00		12.00
H0154	016	0	1	01	01	H0154_016_0	4			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	117.50																									47.00	94.00	141.00				39.50	78.50	94.00				47.00				47.00		1.57				1.57	1.32	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0154	016	0	1	01	01	H0154_016_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	250.00																									100.00	200.00	300.00				85.00	170.00	200.00				100.00				100.00		3.33				3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0154	016	0	1	01	01	H0154_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				1.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	017	0	1	01	01	H0154_017_0	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									4.00	8.00	12.00				0.00	0.00	0.00				0.00				0.00		0.00				0.13	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				4.00	8.00	12.00	0.00	0.00	0.00	0.00		0.00
H0154	017	0	1	01	01	H0154_017_0	4			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	12.00	24.00	30.00																									12.00	24.00	36.00				10.00	20.00	24.00				12.00				12.00		0.40				0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	30.00				12.00	24.00	36.00	10.00	20.00	24.00	12.00		12.00
H0154	017	0	1	01	01	H0154_017_0	4			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	117.50																									47.00	94.00	141.00				39.50	78.50	94.00				47.00				47.00		1.57				1.57	1.32	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0154	017	0	1	01	01	H0154_017_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	250.00																									100.00	200.00	300.00				85.00	170.00	200.00				100.00				100.00		3.33				3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0154	017	0	1	01	01	H0154_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				1.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	019	0	1	01	01	H0154_019_0	4		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H0154	019	0	1	01	01	H0154_019_0	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0154	019	0	1	01	01	H0154_019_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0154	019	0	1	01	01	H0154_019_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0154	019	0	1	01	01	H0154_019_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0154	020	0	1	01	01	H0154_020_0	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									4.00	8.00	12.00				0.00	0.00	0.00				0.00				0.00		0.00				0.13	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				4.00	8.00	12.00	0.00	0.00	0.00	0.00		0.00
H0154	020	0	1	01	01	H0154_020_0	4			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	12.00	24.00	30.00																									12.00	24.00	36.00				10.00	20.00	24.00				12.00				12.00		0.40				0.40	0.33	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	30.00				12.00	24.00	36.00	10.00	20.00	24.00	12.00		12.00
H0154	020	0	1	01	01	H0154_020_0	4			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	117.50																									47.00	94.00	141.00				39.50	78.50	94.00				47.00				47.00		1.57				1.57	1.32	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0154	020	0	1	01	01	H0154_020_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	250.00																									100.00	200.00	300.00				85.00	170.00	200.00				100.00				100.00		3.33				3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0154	020	0	1	01	01	H0154_020_0	4			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				1.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H0174	002	0	1	01	01	H0174_002_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	002	0	1	01	01	H0174_002_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0174	002	0	1	01	01	H0174_002_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	002	0	1	01	01	H0174_002_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	002	0	1	01	01	H0174_002_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.48	49	49	49				99.48	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	002	0	1	01	01	H0174_002_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	002	0	1	01	01	H0174_002_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	002	0	1	01	01	H0174_002_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0174	009	0	1	01	01	H0174_009_0	19			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	009	0	1	01	01	H0174_009_0	19			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	009	0	1	01	01	H0174_009_0	19			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0174	009	0	1	01	01	H0174_009_0	19			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.99	45	45	45				99.99	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	009	0	1	01	01	H0174_009_0	19			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	009	0	1	01	01	H0174_009_0	19			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	010	0	1	01	01	H0174_010_0	20			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	010	0	1	01	01	H0174_010_0	20			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0174	010	0	1	01	01	H0174_010_0	20			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	010	0	1	01	01	H0174_010_0	20			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	010	0	1	01	01	H0174_010_0	20			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.66	49	49	49				99.66	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	010	0	1	01	01	H0174_010_0	20			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	010	0	1	01	01	H0174_010_0	20			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	010	0	1	01	01	H0174_010_0	20			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0174	014	0	1	01	01	H0174_014_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	014	0	1	01	01	H0174_014_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0174	014	0	1	01	01	H0174_014_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	014	0	1	01	01	H0174_014_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	014	0	1	01	01	H0174_014_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.40	49	49	49				99.40	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	014	0	1	01	01	H0174_014_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	014	0	1	01	01	H0174_014_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	014	0	1	01	01	H0174_014_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0174	015	0	1	01	01	H0174_015_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	015	0	1	01	01	H0174_015_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0174	015	0	1	01	01	H0174_015_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	0.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	015	0	1	01	01	H0174_015_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	015	0	1	01	01	H0174_015_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.19	43	43	43				98.19	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	015	0	1	01	01	H0174_015_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	015	0	1	01	01	H0174_015_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	015	0	1	01	01	H0174_015_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0174	016	0	1	01	01	H0174_016_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	016	0	1	01	01	H0174_016_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0174	016	0	1	01	01	H0174_016_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	0.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	016	0	1	01	01	H0174_016_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	016	0	1	01	01	H0174_016_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.84	49	49	49				98.84	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	016	0	1	01	01	H0174_016_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	016	0	1	01	01	H0174_016_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	016	0	1	01	01	H0174_016_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0174	017	0	1	01	01	H0174_017_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	017	0	1	01	01	H0174_017_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	017	0	1	01	01	H0174_017_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	017	0	1	01	01	H0174_017_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.76	50	50	50				85.76	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	017	0	1	01	01	H0174_017_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	017	0	1	01	01	H0174_017_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	018	0	1	01	01	H0174_018_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	018	0	1	01	01	H0174_018_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					2.00	4.00	6.00											15.00	30.00	45.00				2.00	4.00	0.00				15.00				15.00			0.50	0.07		0.50	0.07	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	018	0	1	01	01	H0174_018_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	018	0	1	01	01	H0174_018_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.85	48	48	48				98.85	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	018	0	1	01	01	H0174_018_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	018	0	1	01	01	H0174_018_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	019	0	1	01	01	H0174_019_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	019	0	1	01	01	H0174_019_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	019	0	1	01	01	H0174_019_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	019	0	1	01	01	H0174_019_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.25	47	47	47				99.25	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	019	0	1	01	01	H0174_019_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	019	0	1	01	01	H0174_019_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	020	0	1	01	01	H0174_020_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	020	0	1	01	01	H0174_020_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	020	0	1	01	01	H0174_020_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	020	0	1	01	01	H0174_020_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.88	48	48	48				99.88	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	020	0	1	01	01	H0174_020_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	020	0	1	01	01	H0174_020_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	021	0	1	01	01	H0174_021_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	021	0	1	01	01	H0174_021_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0174	021	0	1	01	01	H0174_021_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0174	021	0	1	01	01	H0174_021_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.32	38	38	38				98.32	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0174	021	0	1	01	01	H0174_021_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0174	021	0	1	01	01	H0174_021_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0192	001	0	1	48	05	H0192_001_0	7			Generic Drugs	4	01		2	1	1	111		01	100		1	30	60	100				1	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0192	001	0	1	48	05	H0192_001_0	7			Brand Drugs	4	11		2	2	1	111		01	100		1	30	60	100				1	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0192	001	0	1	48	05	H0192_001_0	7			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	100		1	30	60	100				1	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0270	001	0	1	04	01	H0270_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0270	001	0	1	04	01	H0270_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0270	001	0	1	04	01	H0270_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0270	001	0	1	04	01	H0270_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.14	50	50	50				80.14	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0270	001	0	1	04	01	H0270_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0270	001	0	1	04	01	H0270_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0271	052	0	1	04	01	H0271_052_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0271	052	0	1	04	01	H0271_052_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0271	052	0	1	04	01	H0271_052_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0271	052	0	1	04	01	H0271_052_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0271	052	0	1	04	01	H0271_052_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0271	052	0	1	04	01	H0271_052_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0271	052	0	1	04	01	H0271_052_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				505.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0271	057	0	1	04	01	H0271_057_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0271	057	0	1	04	01	H0271_057_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0271	057	0	1	04	01	H0271_057_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0271	057	0	1	04	01	H0271_057_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0271	057	0	1	04	01	H0271_057_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0271	057	0	1	04	01	H0271_057_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0271	057	0	1	04	01	H0271_057_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				510.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0292	001	0	1	01	01	H0292_001_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0292	001	0	1	01	01	H0292_001_0	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0292	001	0	1	01	01	H0292_001_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0292	001	0	1	01	01	H0292_001_0	8			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0292	001	0	1	01	01	H0292_001_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0292	001	0	1	01	01	H0292_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0292	001	0	1	01	01	H0292_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0292	002	0	1	01	01	H0292_002_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0292	002	0	1	01	01	H0292_002_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0292	002	0	1	01	01	H0292_002_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0292	002	0	1	01	01	H0292_002_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0292	002	0	1	01	01	H0292_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0292	002	0	1	01	01	H0292_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0292	002	0	1	01	01	H0292_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0292	003	0	1	01	01	H0292_003_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0292	003	0	1	01	01	H0292_003_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0292	003	0	1	01	01	H0292_003_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0292	003	0	1	01	01	H0292_003_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0292	003	0	1	01	01	H0292_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0292	003	0	1	01	01	H0292_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0292	003	0	1	01	01	H0292_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0294	002	0	1	04	01	H0294_002_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	002	0	1	04	01	H0294_002_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	002	0	1	04	01	H0294_002_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	002	0	1	04	01	H0294_002_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	002	0	1	04	01	H0294_002_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0294	002	0	1	04	01	H0294_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	002	0	1	04	01	H0294_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				641.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	004	0	1	04	01	H0294_004_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	004	0	1	04	01	H0294_004_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	004	0	1	04	01	H0294_004_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	004	0	1	04	01	H0294_004_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	004	0	1	04	01	H0294_004_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	004	0	1	04	01	H0294_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	004	0	1	04	01	H0294_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				304.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	010	0	1	04	01	H0294_010_0	10			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	010	0	1	04	01	H0294_010_0	10			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	010	0	1	04	01	H0294_010_0	10			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	010	0	1	04	01	H0294_010_0	10			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	010	0	1	04	01	H0294_010_0	10			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0294	010	0	1	04	01	H0294_010_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	010	0	1	04	01	H0294_010_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				713.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	011	0	1	04	01	H0294_011_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	011	0	1	04	01	H0294_011_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	011	0	1	04	01	H0294_011_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	011	0	1	04	01	H0294_011_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	011	0	1	04	01	H0294_011_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	011	0	1	04	01	H0294_011_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	011	0	1	04	01	H0294_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				267.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	012	0	1	04	01	H0294_012_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	012	0	1	04	01	H0294_012_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	012	0	1	04	01	H0294_012_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	012	0	1	04	01	H0294_012_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	012	0	1	04	01	H0294_012_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	012	0	1	04	01	H0294_012_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	012	0	1	04	01	H0294_012_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				421.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	015	0	1	04	01	H0294_015_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	015	0	1	04	01	H0294_015_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	015	0	1	04	01	H0294_015_0	7			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	015	0	1	04	01	H0294_015_0	7			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	015	0	1	04	01	H0294_015_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H0294	015	0	1	04	01	H0294_015_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H0294	015	0	1	04	01	H0294_015_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											554.00	33						379.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	016	0	1	04	01	H0294_016_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	016	0	1	04	01	H0294_016_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	016	0	1	04	01	H0294_016_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	016	0	1	04	01	H0294_016_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	016	0	1	04	01	H0294_016_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	016	0	1	04	01	H0294_016_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	016	0	1	04	01	H0294_016_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				547.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	017	0	1	04	01	H0294_017_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	017	0	1	04	01	H0294_017_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	017	0	1	04	01	H0294_017_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	017	0	1	04	01	H0294_017_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	017	0	1	04	01	H0294_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	017	0	1	04	01	H0294_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	017	0	1	04	01	H0294_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				519.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	018	0	1	04	01	H0294_018_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	018	0	1	04	01	H0294_018_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	018	0	1	04	01	H0294_018_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	018	0	1	04	01	H0294_018_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	018	0	1	04	01	H0294_018_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	018	0	1	04	01	H0294_018_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	018	0	1	04	01	H0294_018_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				546.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	019	0	1	04	01	H0294_019_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	019	0	1	04	01	H0294_019_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	019	0	1	04	01	H0294_019_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	019	0	1	04	01	H0294_019_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	019	0	1	04	01	H0294_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	019	0	1	04	01	H0294_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	019	0	1	04	01	H0294_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				515.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	020	0	1	04	01	H0294_020_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	020	0	1	04	01	H0294_020_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	020	0	1	04	01	H0294_020_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	020	0	1	04	01	H0294_020_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	020	0	1	04	01	H0294_020_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	020	0	1	04	01	H0294_020_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	020	0	1	04	01	H0294_020_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				535.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	021	0	1	04	01	H0294_021_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	021	0	1	04	01	H0294_021_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	021	0	1	04	01	H0294_021_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	021	0	1	04	01	H0294_021_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	021	0	1	04	01	H0294_021_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	021	0	1	04	01	H0294_021_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	021	0	1	04	01	H0294_021_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				591.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	023	0	1	04	01	H0294_023_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	023	0	1	04	01	H0294_023_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	023	0	1	04	01	H0294_023_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	023	0	1	04	01	H0294_023_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	023	0	1	04	01	H0294_023_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	023	0	1	04	01	H0294_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	023	0	1	04	01	H0294_023_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				454.00	26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	024	0	1	04	01	H0294_024_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	024	0	1	04	01	H0294_024_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	024	0	1	04	01	H0294_024_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	024	0	1	04	01	H0294_024_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	024	0	1	04	01	H0294_024_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	024	0	1	04	01	H0294_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	024	0	1	04	01	H0294_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				458.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	025	0	1	04	01	H0294_025_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	025	0	1	04	01	H0294_025_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	025	0	1	04	01	H0294_025_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	025	0	1	04	01	H0294_025_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	025	0	1	04	01	H0294_025_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	025	0	1	04	01	H0294_025_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	025	0	1	04	01	H0294_025_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				535.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	026	0	1	04	01	H0294_026_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	026	0	1	04	01	H0294_026_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	026	0	1	04	01	H0294_026_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	026	0	1	04	01	H0294_026_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	026	0	1	04	01	H0294_026_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	026	0	1	04	01	H0294_026_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	026	0	1	04	01	H0294_026_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				431.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	028	0	1	04	01	H0294_028_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	028	0	1	04	01	H0294_028_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	028	0	1	04	01	H0294_028_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	028	0	1	04	01	H0294_028_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	028	0	1	04	01	H0294_028_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	028	0	1	04	01	H0294_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	028	0	1	04	01	H0294_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				519.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	029	0	1	04	01	H0294_029_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	029	0	1	04	01	H0294_029_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	029	0	1	04	01	H0294_029_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	029	0	1	04	01	H0294_029_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	029	0	1	04	01	H0294_029_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	029	0	1	04	01	H0294_029_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	029	0	1	04	01	H0294_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				477.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	030	0	1	04	01	H0294_030_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	030	0	1	04	01	H0294_030_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	030	0	1	04	01	H0294_030_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	030	0	1	04	01	H0294_030_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	030	0	1	04	01	H0294_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	030	0	1	04	01	H0294_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	030	0	1	04	01	H0294_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	031	0	1	04	01	H0294_031_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	031	0	1	04	01	H0294_031_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	031	0	1	04	01	H0294_031_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	031	0	1	04	01	H0294_031_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	031	0	1	04	01	H0294_031_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	031	0	1	04	01	H0294_031_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	031	0	1	04	01	H0294_031_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				544.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	032	0	1	04	01	H0294_032_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	032	0	1	04	01	H0294_032_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	032	0	1	04	01	H0294_032_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	032	0	1	04	01	H0294_032_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	032	0	1	04	01	H0294_032_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	032	0	1	04	01	H0294_032_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	032	0	1	04	01	H0294_032_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				414.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	033	0	1	04	01	H0294_033_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	033	0	1	04	01	H0294_033_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	033	0	1	04	01	H0294_033_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	033	0	1	04	01	H0294_033_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	033	0	1	04	01	H0294_033_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	033	0	1	04	01	H0294_033_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	033	0	1	04	01	H0294_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				421.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	034	0	1	04	01	H0294_034_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	034	0	1	04	01	H0294_034_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	034	0	1	04	01	H0294_034_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	034	0	1	04	01	H0294_034_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	034	0	1	04	01	H0294_034_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	034	0	1	04	01	H0294_034_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	034	0	1	04	01	H0294_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	035	0	1	04	01	H0294_035_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	035	0	1	04	01	H0294_035_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	035	0	1	04	01	H0294_035_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	035	0	1	04	01	H0294_035_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	035	0	1	04	01	H0294_035_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	035	0	1	04	01	H0294_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	035	0	1	04	01	H0294_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				405.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	036	0	1	04	01	H0294_036_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	036	0	1	04	01	H0294_036_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	036	0	1	04	01	H0294_036_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	036	0	1	04	01	H0294_036_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	036	0	1	04	01	H0294_036_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	036	0	1	04	01	H0294_036_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	036	0	1	04	01	H0294_036_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				416.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	037	0	1	04	01	H0294_037_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	037	0	1	04	01	H0294_037_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	037	0	1	04	01	H0294_037_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	037	0	1	04	01	H0294_037_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	037	0	1	04	01	H0294_037_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	037	0	1	04	01	H0294_037_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	037	0	1	04	01	H0294_037_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				395.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	038	0	1	04	01	H0294_038_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	038	0	1	04	01	H0294_038_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	038	0	1	04	01	H0294_038_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	038	0	1	04	01	H0294_038_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	038	0	1	04	01	H0294_038_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	038	0	1	04	01	H0294_038_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	038	0	1	04	01	H0294_038_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	039	0	1	04	01	H0294_039_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	039	0	1	04	01	H0294_039_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	039	0	1	04	01	H0294_039_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	039	0	1	04	01	H0294_039_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	039	0	1	04	01	H0294_039_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	039	0	1	04	01	H0294_039_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	039	0	1	04	01	H0294_039_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	040	0	1	04	01	H0294_040_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	040	0	1	04	01	H0294_040_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	040	0	1	04	01	H0294_040_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	040	0	1	04	01	H0294_040_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	040	0	1	04	01	H0294_040_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	040	0	1	04	01	H0294_040_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	040	0	1	04	01	H0294_040_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				544.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	041	0	1	04	01	H0294_041_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	041	0	1	04	01	H0294_041_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	041	0	1	04	01	H0294_041_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	041	0	1	04	01	H0294_041_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	041	0	1	04	01	H0294_041_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	041	0	1	04	01	H0294_041_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	041	0	1	04	01	H0294_041_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				523.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	042	0	1	04	01	H0294_042_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	042	0	1	04	01	H0294_042_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	042	0	1	04	01	H0294_042_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	042	0	1	04	01	H0294_042_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	042	0	1	04	01	H0294_042_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	042	0	1	04	01	H0294_042_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	042	0	1	04	01	H0294_042_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				303.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	043	0	1	04	01	H0294_043_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	043	0	1	04	01	H0294_043_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	043	0	1	04	01	H0294_043_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	043	0	1	04	01	H0294_043_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	043	0	1	04	01	H0294_043_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	043	0	1	04	01	H0294_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	043	0	1	04	01	H0294_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				487.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	044	0	1	04	01	H0294_044_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	044	0	1	04	01	H0294_044_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	044	0	1	04	01	H0294_044_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	044	0	1	04	01	H0294_044_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	9.00		27.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	044	0	1	04	01	H0294_044_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	044	0	1	04	01	H0294_044_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	044	0	1	04	01	H0294_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	046	0	1	04	01	H0294_046_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	046	0	1	04	01	H0294_046_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	046	0	1	04	01	H0294_046_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	046	0	1	04	01	H0294_046_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	046	0	1	04	01	H0294_046_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	046	0	1	04	01	H0294_046_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	046	0	1	04	01	H0294_046_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	047	0	1	04	01	H0294_047_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	047	0	1	04	01	H0294_047_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0294	047	0	1	04	01	H0294_047_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0294	047	0	1	04	01	H0294_047_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0294	047	0	1	04	01	H0294_047_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	047	0	1	04	01	H0294_047_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0294	047	0	1	04	01	H0294_047_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0302	001	0	1	01	01	H0302_001_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0302	001	0	1	01	01	H0302_001_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00
H0302	001	0	1	01	01	H0302_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0302	001	0	1	01	01	H0302_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0302	001	0	1	01	01	H0302_001_0	7			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					33	33																																				33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00											35.00		35.00
H0302	001	0	1	01	01	H0302_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0302	006	0	1	01	01	H0302_006_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0302	006	0	1	01	01	H0302_006_0	8			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00
H0302	006	0	1	01	01	H0302_006_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0302	006	0	1	01	01	H0302_006_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0302	006	0	1	01	01	H0302_006_0	8			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					33	33																																				33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00											35.00		35.00
H0302	006	0	1	01	01	H0302_006_0	8			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0302	008	0	1	01	01	H0302_008_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0302	008	0	1	01	01	H0302_008_0	8			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00
H0302	008	0	1	01	01	H0302_008_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0302	008	0	1	01	01	H0302_008_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0302	008	0	1	01	01	H0302_008_0	8			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					33	33																																				33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00											35.00		35.00
H0302	008	0	1	01	01	H0302_008_0	8			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0332	002	0	1	01	01	H0332_002_0	12			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	002	0	1	01	01	H0332_002_0	12			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	002	0	1	01	01	H0332_002_0	12			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	002	0	1	01	01	H0332_002_0	12			Generic	4	11	3	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0332	002	0	1	01	01	H0332_002_0	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								45.00	90.00	135.00					40.00	80.00	100.00											45.00	90.00	135.00				40.00	80.00	100.00				45.00				45.00			1.50	1.33		1.50	1.33	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	002	0	1	01	01	H0332_002_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								90.00	180.00	270.00					80.00	160.00	200.00											90.00	180.00	270.00				80.00	160.00	200.00				90.00				90.00			3.00	2.67		3.00	2.67	2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	002	0	1	01	01	H0332_002_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0332	002	0	1	01	01	H0332_002_0	12			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	002	0	1	01	01	H0332_002_0	12			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	004	0	1	02	01	H0332_004_0	11			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	004	0	1	02	01	H0332_004_0	11			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	004	0	1	02	01	H0332_004_0	11			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	004	0	1	02	01	H0332_004_0	11			Generic	4	11	3	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0332	004	0	1	02	01	H0332_004_0	11			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								45.00	90.00	135.00					40.00	80.00	100.00											45.00	90.00	135.00				40.00	80.00	100.00				45.00				45.00			1.50	1.33		1.50	1.33	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	004	0	1	02	01	H0332_004_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								90.00	180.00	270.00					80.00	160.00	200.00											90.00	180.00	270.00				80.00	160.00	200.00				90.00				90.00			3.00	2.67		3.00	2.67	2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	004	0	1	02	01	H0332_004_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0332	004	0	1	02	01	H0332_004_0	11			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	004	0	1	02	01	H0332_004_0	11			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	009	0	1	01	01	H0332_009_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	009	0	1	01	01	H0332_009_0	9			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	009	0	1	01	01	H0332_009_0	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	009	0	1	01	01	H0332_009_0	9			Generic	4	11	3	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0332	009	0	1	01	01	H0332_009_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	100.00											47.00	94.00	141.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	009	0	1	01	01	H0332_009_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					80.00	160.00	200.00											100.00	200.00	300.00				80.00	160.00	200.00				100.00				100.00			3.33	2.67		3.33	2.67	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	009	0	1	01	01	H0332_009_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0332	009	0	1	01	01	H0332_009_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	009	0	1	01	01	H0332_009_0	9			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	010	0	1	01	01	H0332_010_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	010	0	1	01	01	H0332_010_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	010	0	1	01	01	H0332_010_0	8			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	010	0	1	01	01	H0332_010_0	8			Generic	4	11	3	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0332	010	0	1	01	01	H0332_010_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	100.00											47.00	94.00	141.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	87.50	35.00	70.00	87.50	35.00		35.00
H0332	010	0	1	01	01	H0332_010_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					80.00	160.00	200.00											100.00	200.00	300.00				80.00	160.00	200.00				100.00				100.00			3.33	2.67		3.33	2.67	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	010	0	1	01	01	H0332_010_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0332	010	0	1	01	01	H0332_010_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	010	0	1	01	01	H0332_010_0	8			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	011	0	1	02	01	H0332_011_0	10			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	011	0	1	02	01	H0332_011_0	10			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0332	011	0	1	02	01	H0332_011_0	10			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	13.00											15.00	30.00	45.00				5.00	10.00	13.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	011	0	1	02	01	H0332_011_0	10			Generic	4	11	3	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	13.00											15.00	30.00	45.00				5.00	10.00	13.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0332	011	0	1	02	01	H0332_011_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	113.00											47.00	94.00	141.00				45.00	90.00	113.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	011	0	1	02	01	H0332_011_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					90.00	180.00	225.00											100.00	200.00	300.00				90.00	180.00	225.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00
H0332	011	0	1	02	01	H0332_011_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0332	011	0	1	02	01	H0332_011_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0332	011	0	1	02	01	H0332_011_0	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0336	001	0	1	48	05	H0336_001_0	2			Generic Drugs	4	01		2	1	1	110		01	110		1	30		90				2	2	30		90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0336	001	0	1	48	05	H0336_001_0	2			Brand Drugs	4	10		2	2	1	110		01	110		1	30		90				2	2	30		90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0336	001	0	1	48	05	H0336_001_0	2			Non-Medicare Rx Drugs	4	11		2	3	1	110		01	110		1	30		90				1	2	30		90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0336	001	0	1	48	05	H0336_001_0	2			Non-Medicare OTC Drugs	4	11		2	4	1	110		01	110		1	30		90				1	2	30		90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0342	001	0	1	04	01	H0342_001_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		0.00
H0342	001	0	1	04	01	H0342_001_0	6			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H0342	001	0	1	04	01	H0342_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0342	001	0	1	04	01	H0342_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0342	001	0	1	04	01	H0342_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0342	001	0	1	04	01	H0342_001_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0342	001	0	1	04	01	H0342_001_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0351	038	0	1	01	01	H0351_038_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	038	0	1	01	01	H0351_038_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2	3															
H0351	038	0	1	01	01	H0351_038_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					4.00	8.00	12.00											7.00	14.00	21.00				4.00	8.00	0.00				7.00				7.00			0.23	0.13		0.23	0.13	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	038	0	1	01	01	H0351_038_0	17			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					4.00	8.00	12.00											7.00	14.00	21.00				4.00	8.00	0.00				7.00				7.00			0.23	0.13		0.23	0.13	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0351	038	0	1	01	01	H0351_038_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	038	0	1	01	01	H0351_038_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.05	37	37	37				99.05	37	37	37										37	37	37				37	37	37			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	038	0	1	01	01	H0351_038_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	038	0	1	01	01	H0351_038_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H0351	038	0	1	01	01	H0351_038_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	1																
H0351	053	0	1	01	01	H0351_053_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	053	0	1	01	01	H0351_053_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	053	0	1	01	01	H0351_053_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0351	053	0	1	01	01	H0351_053_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.32	39	39	39				99.32	39	39	39										39	39	39				39	39	39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	053	0	1	01	01	H0351_053_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	053	0	1	01	01	H0351_053_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	053	0	1	01	01	H0351_053_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0351	054	0	1	01	01	H0351_054_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	054	0	1	01	01	H0351_054_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	054	0	1	01	01	H0351_054_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0351	054	0	1	01	01	H0351_054_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.82	50	50	50				97.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	054	0	1	01	01	H0351_054_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	054	0	1	01	01	H0351_054_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	057	0	1	01	01	H0351_057_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	057	0	1	01	01	H0351_057_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2	3															
H0351	057	0	1	01	01	H0351_057_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					1.00	2.00	3.00											15.00	30.00	45.00				1.00	2.00	0.00				15.00				15.00			0.50	0.03		0.50	0.03	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	057	0	1	01	01	H0351_057_0	17			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					1.00	2.00	3.00											15.00	30.00	45.00				1.00	2.00	0.00				15.00				15.00			0.50	0.03		0.50	0.03	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0351	057	0	1	01	01	H0351_057_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	057	0	1	01	01	H0351_057_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.95	38	38	38				99.95	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	057	0	1	01	01	H0351_057_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	057	0	1	01	01	H0351_057_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00	10.00		10.00
H0351	057	0	1	01	01	H0351_057_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	1																
H0351	061	0	1	01	01	H0351_061_0	17			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	061	0	1	01	01	H0351_061_0	17			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	061	0	1	01	01	H0351_061_0	17			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0351	061	0	1	01	01	H0351_061_0	17			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.11	45	45	45				99.11	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	061	0	1	01	01	H0351_061_0	17			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	061	0	1	01	01	H0351_061_0	17			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	062	0	1	01	01	H0351_062_0	16			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	062	0	1	01	01	H0351_062_0	16			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	062	0	1	01	01	H0351_062_0	16			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0351	062	0	1	01	01	H0351_062_0	16			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.17	44	44	44				99.17	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	062	0	1	01	01	H0351_062_0	16			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	062	0	1	01	01	H0351_062_0	16			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	063	0	1	01	01	H0351_063_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	063	0	1	01	01	H0351_063_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	063	0	1	01	01	H0351_063_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0351	063	0	1	01	01	H0351_063_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.82	37	37	37				97.82	37	37	37										37	37	37				37	37	37			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	063	0	1	01	01	H0351_063_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	063	0	1	01	01	H0351_063_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	063	0	1	01	01	H0351_063_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0351	064	0	1	01	01	H0351_064_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	064	0	1	01	01	H0351_064_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0351	064	0	1	01	01	H0351_064_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0351	064	0	1	01	01	H0351_064_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.96	32	32	32				98.96	32	32	32										32	32	32				32	32	32			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0351	064	0	1	01	01	H0351_064_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0351	064	0	1	01	01	H0351_064_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0354	001	0	1	01	01	H0354_001_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0354	001	0	1	01	01	H0354_001_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0354	001	0	1	01	01	H0354_001_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	10.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H0354	001	0	1	01	01	H0354_001_0	9			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0354	001	0	1	01	01	H0354_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	001	0	1	01	01	H0354_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	001	0	1	01	01	H0354_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											620.24	33						450.22	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0354	027	0	1	01	01	H0354_027_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0354	027	0	1	01	01	H0354_027_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H0354	027	0	1	01	01	H0354_027_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													20.00	40.00	60.00	5.00	10.00	10.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H0354	027	0	1	01	01	H0354_027_0	9			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H0354	027	0	1	01	01	H0354_027_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	027	0	1	01	01	H0354_027_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	027	0	1	01	01	H0354_027_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											704.43	33						414.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0354	027	0	1	01	01	H0354_027_0	9			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					9.00	18.00	18.00											11.00	22.00	33.00				9.00	18.00	18.00				11.00				11.00			0.37	0.30		0.37	0.30	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00	22.00	33.00	9.00	18.00	18.00	11.00	22.00	33.00	9.00	18.00	18.00	11.00		11.00
H0354	028	0	1	01	01	H0354_028_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0354	028	0	1	01	01	H0354_028_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0354	028	0	1	01	01	H0354_028_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	10.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H0354	028	0	1	01	01	H0354_028_0	9			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0354	028	0	1	01	01	H0354_028_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	028	0	1	01	01	H0354_028_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	028	0	1	01	01	H0354_028_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											599.16	33						521.54	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0354	029	0	1	01	01	H0354_029_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0354	029	0	1	01	01	H0354_029_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0354	029	0	1	01	01	H0354_029_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	10.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H0354	029	0	1	01	01	H0354_029_0	8			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0354	029	0	1	01	01	H0354_029_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	029	0	1	01	01	H0354_029_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0354	029	0	1	01	01	H0354_029_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											636.61	33						479.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0422	001	0	1	02	01	H0422_001_0	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	001	0	1	02	01	H0422_001_0	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	15.00	30.00	45.00																			15.00	30.00	30.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	001	0	1	02	01	H0422_001_0	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H0422	001	0	1	02	01	H0422_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	001	0	1	02	01	H0422_001_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1997.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	003	0	1	02	01	H0422_003_0	9			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	003	0	1	02	01	H0422_003_0	9			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	15.00	30.00	45.00																			15.00	30.00	30.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	003	0	1	02	01	H0422_003_0	9			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H0422	003	0	1	02	01	H0422_003_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0422	003	0	1	02	01	H0422_003_0	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2386.00	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	003	0	1	02	01	H0432_003_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	003	0	1	02	01	H0432_003_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0432	003	0	1	02	01	H0432_003_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	003	0	1	02	01	H0432_003_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0432	003	0	1	02	01	H0432_003_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0432	003	0	1	02	01	H0432_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0432	003	0	1	02	01	H0432_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	004	0	1	02	01	H0432_004_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	004	0	1	02	01	H0432_004_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0432	004	0	1	02	01	H0432_004_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	004	0	1	02	01	H0432_004_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0432	004	0	1	02	01	H0432_004_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0432	004	0	1	02	01	H0432_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0432	004	0	1	02	01	H0432_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	017	0	1	02	01	H0432_017_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	017	0	1	02	01	H0432_017_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0432	017	0	1	02	01	H0432_017_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0432	017	0	1	02	01	H0432_017_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0432	017	0	1	02	01	H0432_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0432	017	0	1	02	01	H0432_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0432	017	0	1	02	01	H0432_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				432.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0439	003	1	1	01	01	H0439_003_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0439	003	1	1	01	01	H0439_003_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	003	1	1	01	01	H0439_003_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H0439	003	1	1	01	01	H0439_003_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	003	1	1	01	01	H0439_003_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											96.10	38	38	38				90.75	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	003	1	1	01	01	H0439_003_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											646.21	30						437.04	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	003	2	1	01	01	H0439_003_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0439	003	2	1	01	01	H0439_003_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	003	2	1	01	01	H0439_003_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H0439	003	2	1	01	01	H0439_003_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	003	2	1	01	01	H0439_003_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											96.10	38	38	38				90.75	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	003	2	1	01	01	H0439_003_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											646.21	30						437.04	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	006	0	1	01	01	H0439_006_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0439	006	0	1	01	01	H0439_006_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	006	0	1	01	01	H0439_006_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0439	006	0	1	01	01	H0439_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	006	0	1	01	01	H0439_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	006	0	1	01	01	H0439_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											609.06	33						618.08	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	007	0	1	01	01	H0439_007_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0439	007	0	1	01	01	H0439_007_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	007	0	1	01	01	H0439_007_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H0439	007	0	1	01	01	H0439_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	007	0	1	01	01	H0439_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	007	0	1	01	01	H0439_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											620.41	33						476.90	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	008	0	1	01	01	H0439_008_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0439	008	0	1	01	01	H0439_008_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	008	0	1	01	01	H0439_008_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H0439	008	0	1	01	01	H0439_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	008	0	1	01	01	H0439_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	008	0	1	01	01	H0439_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											815.73	33						656.50	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	009	0	1	01	01	H0439_009_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0439	009	0	1	01	01	H0439_009_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	009	0	1	01	01	H0439_009_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H0439	009	0	1	01	01	H0439_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	009	0	1	01	01	H0439_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	009	0	1	01	01	H0439_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											643.51	33						546.49	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	010	0	1	01	01	H0439_010_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0439	010	0	1	01	01	H0439_010_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	010	0	1	01	01	H0439_010_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0439	010	0	1	01	01	H0439_010_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	010	0	1	01	01	H0439_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	010	0	1	01	01	H0439_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											777.90	33						552.28	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	011	0	1	01	01	H0439_011_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0439	011	0	1	01	01	H0439_011_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	011	0	1	01	01	H0439_011_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H0439	011	0	1	01	01	H0439_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	011	0	1	01	01	H0439_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	011	0	1	01	01	H0439_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											745.19	33						532.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0439	013	0	1	01	01	H0439_013_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0439	013	0	1	01	01	H0439_013_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0439	013	0	1	01	01	H0439_013_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H0439	013	0	1	01	01	H0439_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	013	0	1	01	01	H0439_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0439	013	0	1	01	01	H0439_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											622.96	33						485.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0473	001	0	1	04	01	H0473_001_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0473	001	0	1	04	01	H0473_001_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0473	001	0	1	04	01	H0473_001_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H0473	001	0	1	04	01	H0473_001_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0473	001	0	1	04	01	H0473_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	001	0	1	04	01	H0473_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	001	0	1	04	01	H0473_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0473	003	0	1	04	01	H0473_003_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H0473	003	0	1	04	01	H0473_003_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H0473	003	0	1	04	01	H0473_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	003	0	1	04	01	H0473_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	003	0	1	04	01	H0473_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0473	004	0	1	04	01	H0473_004_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0473	004	0	1	04	01	H0473_004_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0473	004	0	1	04	01	H0473_004_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0473	004	0	1	04	01	H0473_004_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0473	004	0	1	04	01	H0473_004_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	004	0	1	04	01	H0473_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	004	0	1	04	01	H0473_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0473	005	0	1	04	01	H0473_005_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0473	005	0	1	04	01	H0473_005_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0473	005	0	1	04	01	H0473_005_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0473	005	0	1	04	01	H0473_005_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0473	005	0	1	04	01	H0473_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0473	005	0	1	04	01	H0473_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0473	005	0	1	04	01	H0473_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0480	001	0	1	48	05	H0480_001_0	15			Generic Drugs	4	01		2	1	1	110		01	100		1	30		100				2	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0480	001	0	1	48	05	H0480_001_0	15			Brand Drugs	4	10		2	2	1	110		01	100		1	30		100				2	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0480	001	0	1	48	05	H0480_001_0	15			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	110		01	100		1	30		100				1	1			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0482	002	0	1	01	01	H0482_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0482	002	0	1	01	01	H0482_002_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0482	002	0	1	01	01	H0482_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0482	002	0	1	01	01	H0482_002_0	18			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0482	002	0	1	01	01	H0482_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0482	002	0	1	01	01	H0482_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.36	50	50	50				89.36	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0482	002	0	1	01	01	H0482_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0482	002	0	1	01	01	H0482_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0482	002	0	1	01	01	H0482_002_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0482	003	0	1	01	01	H0482_003_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0482	003	0	1	01	01	H0482_003_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0482	003	0	1	01	01	H0482_003_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0482	003	0	1	01	01	H0482_003_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											73.02	50	50	50				73.02	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0482	003	0	1	01	01	H0482_003_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0482	003	0	1	01	01	H0482_003_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0504	015	0	1	01	01	H0504_015_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	015	0	1	01	01	H0504_015_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	015	0	1	01	01	H0504_015_0	5			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								12.00	24.00	36.00					5.00	10.00	7.50							7.50																12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	015	0	1	01	01	H0504_015_0	5			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								12.00	24.00	36.00					5.00	10.00	7.50							7.50																12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	015	0	1	01	01	H0504_015_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					38.00	76.00	95.00							95.00																47.00				47.00			1.57	1.27				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	95.00			95.00				35.00		35.00
H0504	015	0	1	01	01	H0504_015_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	015	0	1	01	01	H0504_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	017	0	1	01	01	H0504_017_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	017	0	1	01	01	H0504_017_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	017	0	1	01	01	H0504_017_0	5			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	017	0	1	01	01	H0504_017_0	5			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	017	0	1	01	01	H0504_017_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H0504	017	0	1	01	01	H0504_017_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	017	0	1	01	01	H0504_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	021	0	1	01	01	H0504_021_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	021	0	1	01	01	H0504_021_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	021	0	1	01	01	H0504_021_0	5			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	021	0	1	01	01	H0504_021_0	5			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	021	0	1	01	01	H0504_021_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H0504	021	0	1	01	01	H0504_021_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	021	0	1	01	01	H0504_021_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	026	0	1	01	01	H0504_026_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	026	0	1	01	01	H0504_026_0	6			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	026	0	1	01	01	H0504_026_0	6			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	026	0	1	01	01	H0504_026_0	6			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	026	0	1	01	01	H0504_026_0	6			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H0504	026	0	1	01	01	H0504_026_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	026	0	1	01	01	H0504_026_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	028	0	1	01	01	H0504_028_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	028	0	1	01	01	H0504_028_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	028	0	1	01	01	H0504_028_0	5			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	028	0	1	01	01	H0504_028_0	5			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	028	0	1	01	01	H0504_028_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					35.00	70.00	87.50							87.50																47.00				47.00			1.57	1.17				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	25.00	50.00	75.00			75.00				35.00		35.00
H0504	028	0	1	01	01	H0504_028_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	028	0	1	01	01	H0504_028_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	038	0	1	01	01	H0504_038_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	038	0	1	01	01	H0504_038_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	038	0	1	01	01	H0504_038_0	5			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					15.00	30.00	22.50							22.50																20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	038	0	1	01	01	H0504_038_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00			90.00				35.00		35.00
H0504	038	0	1	01	01	H0504_038_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	038	0	1	01	01	H0504_038_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	039	0	1	01	01	H0504_039_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	039	0	1	01	01	H0504_039_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	039	0	1	01	01	H0504_039_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								15.00	30.00	45.00					10.00	20.00	15.00							15.00																15.00				15.00			0.50	0.33				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	039	0	1	01	01	H0504_039_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								15.00	30.00	45.00					10.00	20.00	15.00							15.00																15.00				15.00			0.50	0.33				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0504	039	0	1	01	01	H0504_039_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00			90.00				35.00		35.00
H0504	039	0	1	01	01	H0504_039_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	039	0	1	01	01	H0504_039_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	040	0	1	01	01	H0504_040_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	040	0	1	01	01	H0504_040_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	040	0	1	01	01	H0504_040_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	040	0	1	01	01	H0504_040_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0504	040	0	1	01	01	H0504_040_0	5			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					35.00	70.00	87.50							87.50																47.00				47.00			1.57	1.17				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	25.00	50.00	75.00			75.00				35.00		35.00
H0504	040	0	1	01	01	H0504_040_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	040	0	1	01	01	H0504_040_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	041	0	1	01	01	H0504_041_0	7			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	041	0	1	01	01	H0504_041_0	7			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	041	0	1	01	01	H0504_041_0	7			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								12.00	24.00	36.00					5.00	10.00	7.50							7.50																12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	041	0	1	01	01	H0504_041_0	7			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00			90.00				35.00		35.00
H0504	041	0	1	01	01	H0504_041_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	041	0	1	01	01	H0504_041_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	043	0	1	01	01	H0504_043_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	043	0	1	01	01	H0504_043_0	6			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	043	0	1	01	01	H0504_043_0	6			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	043	0	1	01	01	H0504_043_0	6			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0504	043	0	1	01	01	H0504_043_0	6			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					35.00	70.00	87.50							87.50																47.00				47.00			1.57	1.17				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	25.00	50.00	75.00			75.00				35.00		35.00
H0504	043	0	1	01	01	H0504_043_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	043	0	1	01	01	H0504_043_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	047	0	1	01	01	H0504_047_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	047	0	1	01	01	H0504_047_0	6			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	047	0	1	01	01	H0504_047_0	6			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								18.00	36.00	54.00					10.00	20.00	15.00							15.00																18.00				18.00			0.60	0.33				0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	047	0	1	01	01	H0504_047_0	6			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00			90.00				35.00		35.00
H0504	047	0	1	01	01	H0504_047_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	047	0	1	01	01	H0504_047_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	049	0	1	01	01	H0504_049_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	049	0	1	01	01	H0504_049_0	6			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0504	049	0	1	01	01	H0504_049_0	6			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0504	049	0	1	01	01	H0504_049_0	6			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	30.00					3.00	6.00	4.50							4.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0504	049	0	1	01	01	H0504_049_0	6			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					35.00	70.00	87.50							87.50																47.00				47.00			1.57	1.17				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	25.00	50.00	75.00			75.00				35.00		35.00
H0504	049	0	1	01	01	H0504_049_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H0504	049	0	1	01	01	H0504_049_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	022	0	1	01	01	H0523_022_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	022	0	1	01	01	H0523_022_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0523	022	0	1	01	01	H0523_022_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	022	0	1	01	01	H0523_022_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0523	022	0	1	01	01	H0523_022_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	022	0	1	01	01	H0523_022_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	022	0	1	01	01	H0523_022_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											787.09	33						601.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	052	0	1	01	01	H0523_052_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	052	0	1	01	01	H0523_052_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0523	052	0	1	01	01	H0523_052_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	052	0	1	01	01	H0523_052_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0523	052	0	1	01	01	H0523_052_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	052	0	1	01	01	H0523_052_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	052	0	1	01	01	H0523_052_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											663.14	33						524.72	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	065	0	1	01	01	H0523_065_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	065	0	1	01	01	H0523_065_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	065	0	1	01	01	H0523_065_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	065	0	1	01	01	H0523_065_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	065	0	1	01	01	H0523_065_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	065	0	1	01	01	H0523_065_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	065	0	1	01	01	H0523_065_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											770.28	33						564.66	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	067	0	1	01	01	H0523_067_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	067	0	1	01	01	H0523_067_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	067	0	1	01	01	H0523_067_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	067	0	1	01	01	H0523_067_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	067	0	1	01	01	H0523_067_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	067	0	1	01	01	H0523_067_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	067	0	1	01	01	H0523_067_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											776.54	33						560.08	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	068	0	1	01	01	H0523_068_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	068	0	1	01	01	H0523_068_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	068	0	1	01	01	H0523_068_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	068	0	1	01	01	H0523_068_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	068	0	1	01	01	H0523_068_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	068	0	1	01	01	H0523_068_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	068	0	1	01	01	H0523_068_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											777.67	33						559.27	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	069	0	1	01	01	H0523_069_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	069	0	1	01	01	H0523_069_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	069	0	1	01	01	H0523_069_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	069	0	1	01	01	H0523_069_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	069	0	1	01	01	H0523_069_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	069	0	1	01	01	H0523_069_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	069	0	1	01	01	H0523_069_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											793.44	33						555.99	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	070	0	1	01	01	H0523_070_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	070	0	1	01	01	H0523_070_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	070	0	1	01	01	H0523_070_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	070	0	1	01	01	H0523_070_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	070	0	1	01	01	H0523_070_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	070	0	1	01	01	H0523_070_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	070	0	1	01	01	H0523_070_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.58	33						561.50	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	071	0	1	01	01	H0523_071_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	071	0	1	01	01	H0523_071_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	071	0	1	01	01	H0523_071_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	071	0	1	01	01	H0523_071_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	071	0	1	01	01	H0523_071_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	071	0	1	01	01	H0523_071_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	071	0	1	01	01	H0523_071_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											775.56	33						560.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	072	0	1	01	01	H0523_072_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	072	0	1	01	01	H0523_072_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	072	0	1	01	01	H0523_072_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	072	0	1	01	01	H0523_072_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	072	0	1	01	01	H0523_072_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	072	0	1	01	01	H0523_072_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	072	0	1	01	01	H0523_072_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											773.63	33						560.06	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	073	0	1	01	01	H0523_073_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	073	0	1	01	01	H0523_073_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	073	0	1	01	01	H0523_073_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	073	0	1	01	01	H0523_073_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	073	0	1	01	01	H0523_073_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	073	0	1	01	01	H0523_073_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	073	0	1	01	01	H0523_073_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											747.49	33						566.56	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	074	0	1	02	01	H0523_074_0	8			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	074	0	1	02	01	H0523_074_0	8			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	074	0	1	02	01	H0523_074_0	8			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	074	0	1	02	01	H0523_074_0	8			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	074	0	1	02	01	H0523_074_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	074	0	1	02	01	H0523_074_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	074	0	1	02	01	H0523_074_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	075	0	1	01	01	H0523_075_0	8			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	075	0	1	01	01	H0523_075_0	8			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	075	0	1	01	01	H0523_075_0	8			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	075	0	1	01	01	H0523_075_0	8			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	075	0	1	01	01	H0523_075_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	075	0	1	01	01	H0523_075_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	075	0	1	01	01	H0523_075_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											790.13	33						550.63	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	076	0	1	02	01	H0523_076_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	076	0	1	02	01	H0523_076_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	076	0	1	02	01	H0523_076_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	076	0	1	02	01	H0523_076_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	076	0	1	02	01	H0523_076_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	076	0	1	02	01	H0523_076_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	076	0	1	02	01	H0523_076_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	077	0	1	02	01	H0523_077_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	077	0	1	02	01	H0523_077_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	077	0	1	02	01	H0523_077_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	077	0	1	02	01	H0523_077_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	077	0	1	02	01	H0523_077_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	077	0	1	02	01	H0523_077_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	077	0	1	02	01	H0523_077_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	078	0	1	02	01	H0523_078_0	8			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	078	0	1	02	01	H0523_078_0	8			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	078	0	1	02	01	H0523_078_0	8			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	078	0	1	02	01	H0523_078_0	8			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	078	0	1	02	01	H0523_078_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	078	0	1	02	01	H0523_078_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	078	0	1	02	01	H0523_078_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	079	0	1	02	01	H0523_079_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	079	0	1	02	01	H0523_079_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	079	0	1	02	01	H0523_079_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	079	0	1	02	01	H0523_079_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	079	0	1	02	01	H0523_079_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	079	0	1	02	01	H0523_079_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	079	0	1	02	01	H0523_079_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0523	080	0	1	02	01	H0523_080_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	080	0	1	02	01	H0523_080_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	080	0	1	02	01	H0523_080_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0523	080	0	1	02	01	H0523_080_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0523	080	0	1	02	01	H0523_080_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	080	0	1	02	01	H0523_080_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0523	080	0	1	02	01	H0523_080_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0524	003	0	1	01	01	H0524_003_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	003	0	1	01	01	H0524_003_0	14			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	003	0	1	01	01	H0524_003_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	003	0	1	01	01	H0524_003_0	14			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	003	0	1	01	01	H0524_003_0	14			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	80.00				35.00		35.00
H0524	003	0	1	01	01	H0524_003_0	14			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	003	0	1	01	01	H0524_003_0	14			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	003	0	1	01	01	H0524_003_0	14			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	003	0	1	01	01	H0524_003_0	14			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	008	0	1	01	01	H0524_008_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	008	0	1	01	01	H0524_008_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	008	0	1	01	01	H0524_008_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	008	0	1	01	01	H0524_008_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	008	0	1	01	01	H0524_008_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	008	0	1	01	01	H0524_008_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	008	0	1	01	01	H0524_008_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	008	0	1	01	01	H0524_008_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	008	0	1	01	01	H0524_008_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	013	0	1	01	01	H0524_013_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	013	0	1	01	01	H0524_013_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	013	0	1	01	01	H0524_013_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.26			0.26			0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													8.00	16.00	24.00				8.00	16.00	16.00				8.00		8.00
H0524	013	0	1	01	01	H0524_013_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.26			0.26			0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	013	0	1	01	01	H0524_013_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	013	0	1	01	01	H0524_013_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	013	0	1	01	01	H0524_013_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	013	0	1	01	01	H0524_013_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	013	0	1	01	01	H0524_013_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	015	0	1	01	01	H0524_015_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	015	0	1	01	01	H0524_015_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	015	0	1	01	01	H0524_015_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H0524	015	0	1	01	01	H0524_015_0	13			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	015	0	1	01	01	H0524_015_0	13			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	015	0	1	01	01	H0524_015_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	015	0	1	01	01	H0524_015_0	13			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	015	0	1	01	01	H0524_015_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	015	0	1	01	01	H0524_015_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	031	0	1	01	01	H0524_031_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	031	0	1	01	01	H0524_031_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	031	0	1	01	01	H0524_031_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	031	0	1	01	01	H0524_031_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	031	0	1	01	01	H0524_031_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	031	0	1	01	01	H0524_031_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	031	0	1	01	01	H0524_031_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	031	0	1	01	01	H0524_031_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	031	0	1	01	01	H0524_031_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	032	0	1	01	01	H0524_032_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	032	0	1	01	01	H0524_032_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	032	0	1	01	01	H0524_032_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H0524	032	0	1	01	01	H0524_032_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	032	0	1	01	01	H0524_032_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	032	0	1	01	01	H0524_032_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	032	0	1	01	01	H0524_032_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	032	0	1	01	01	H0524_032_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	032	0	1	01	01	H0524_032_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	033	0	1	01	01	H0524_033_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	033	0	1	01	01	H0524_033_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	033	0	1	01	01	H0524_033_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	033	0	1	01	01	H0524_033_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	033	0	1	01	01	H0524_033_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	033	0	1	01	01	H0524_033_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	033	0	1	01	01	H0524_033_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	033	0	1	01	01	H0524_033_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	033	0	1	01	01	H0524_033_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	034	0	1	01	01	H0524_034_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	034	0	1	01	01	H0524_034_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	034	0	1	01	01	H0524_034_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	034	0	1	01	01	H0524_034_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	034	0	1	01	01	H0524_034_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	84.00				35.00		35.00
H0524	034	0	1	01	01	H0524_034_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	034	0	1	01	01	H0524_034_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	034	0	1	01	01	H0524_034_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	034	0	1	01	01	H0524_034_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	035	0	1	01	01	H0524_035_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	035	0	1	01	01	H0524_035_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	035	0	1	01	01	H0524_035_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	035	0	1	01	01	H0524_035_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	035	0	1	01	01	H0524_035_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	84.00				35.00		35.00
H0524	035	0	1	01	01	H0524_035_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	035	0	1	01	01	H0524_035_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	035	0	1	01	01	H0524_035_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	035	0	1	01	01	H0524_035_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	036	0	1	01	01	H0524_036_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	036	0	1	01	01	H0524_036_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	036	0	1	01	01	H0524_036_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H0524	036	0	1	01	01	H0524_036_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	036	0	1	01	01	H0524_036_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	036	0	1	01	01	H0524_036_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	036	0	1	01	01	H0524_036_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	036	0	1	01	01	H0524_036_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	036	0	1	01	01	H0524_036_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	037	0	1	01	01	H0524_037_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	037	0	1	01	01	H0524_037_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	037	0	1	01	01	H0524_037_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	037	0	1	01	01	H0524_037_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	037	0	1	01	01	H0524_037_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	84.00				35.00		35.00
H0524	037	0	1	01	01	H0524_037_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	037	0	1	01	01	H0524_037_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	037	0	1	01	01	H0524_037_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	037	0	1	01	01	H0524_037_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	038	0	1	01	01	H0524_038_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	038	0	1	01	01	H0524_038_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	038	0	1	01	01	H0524_038_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.26			0.26			0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													8.00	16.00	24.00				8.00	16.00	16.00				8.00		8.00
H0524	038	0	1	01	01	H0524_038_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.26			0.26			0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	038	0	1	01	01	H0524_038_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	038	0	1	01	01	H0524_038_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	038	0	1	01	01	H0524_038_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	038	0	1	01	01	H0524_038_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	038	0	1	01	01	H0524_038_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	039	0	1	01	01	H0524_039_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	039	0	1	01	01	H0524_039_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	039	0	1	01	01	H0524_039_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H0524	039	0	1	01	01	H0524_039_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	039	0	1	01	01	H0524_039_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	039	0	1	01	01	H0524_039_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	039	0	1	01	01	H0524_039_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	039	0	1	01	01	H0524_039_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	039	0	1	01	01	H0524_039_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	040	0	1	01	01	H0524_040_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	040	0	1	01	01	H0524_040_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	040	0	1	01	01	H0524_040_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	040	0	1	01	01	H0524_040_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	040	0	1	01	01	H0524_040_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	040	0	1	01	01	H0524_040_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	040	0	1	01	01	H0524_040_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	040	0	1	01	01	H0524_040_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	040	0	1	01	01	H0524_040_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	041	0	1	01	01	H0524_041_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	041	0	1	01	01	H0524_041_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	041	0	1	01	01	H0524_041_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													12.00	24.00	36.00				12.00	24.00	24.00				12.00		12.00
H0524	041	0	1	01	01	H0524_041_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	041	0	1	01	01	H0524_041_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	041	0	1	01	01	H0524_041_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	041	0	1	01	01	H0524_041_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	041	0	1	01	01	H0524_041_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	041	0	1	01	01	H0524_041_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	042	0	1	01	01	H0524_042_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	042	0	1	01	01	H0524_042_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	042	0	1	01	01	H0524_042_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	6.00	12.00	18.00																			6.00	12.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				6.00	12.00	12.00				6.00		6.00
H0524	042	0	1	01	01	H0524_042_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	6.00	12.00	18.00																			6.00	12.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	042	0	1	01	01	H0524_042_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	042	0	1	01	01	H0524_042_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	042	0	1	01	01	H0524_042_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	042	0	1	01	01	H0524_042_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	042	0	1	01	01	H0524_042_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	043	0	1	01	01	H0524_043_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													3.00	6.00	9.00				3.00	6.00	6.00				3.00		3.00
H0524	043	0	1	01	01	H0524_043_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	043	0	1	01	01	H0524_043_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													12.00	24.00	36.00				12.00	24.00	24.00				12.00		12.00
H0524	043	0	1	01	01	H0524_043_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	043	0	1	01	01	H0524_043_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	043	0	1	01	01	H0524_043_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	043	0	1	01	01	H0524_043_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	043	0	1	01	01	H0524_043_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	043	0	1	01	01	H0524_043_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	046	0	1	01	01	H0524_046_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H0524	046	0	1	01	01	H0524_046_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	046	0	1	01	01	H0524_046_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													18.00	36.00	54.00				18.00	36.00	36.00				18.00		18.00
H0524	046	0	1	01	01	H0524_046_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	046	0	1	01	01	H0524_046_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	046	0	1	01	01	H0524_046_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	046	0	1	01	01	H0524_046_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	046	0	1	01	01	H0524_046_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	046	0	1	01	01	H0524_046_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	051	0	1	01	01	H0524_051_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H0524	051	0	1	01	01	H0524_051_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	051	0	1	01	01	H0524_051_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													18.00	36.00	54.00				18.00	36.00	36.00				18.00		18.00
H0524	051	0	1	01	01	H0524_051_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	051	0	1	01	01	H0524_051_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	051	0	1	01	01	H0524_051_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	051	0	1	01	01	H0524_051_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	051	0	1	01	01	H0524_051_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	051	0	1	01	01	H0524_051_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	054	0	1	01	01	H0524_054_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	054	0	1	01	01	H0524_054_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	054	0	1	01	01	H0524_054_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	054	0	1	01	01	H0524_054_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	054	0	1	01	01	H0524_054_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	054	0	1	01	01	H0524_054_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	054	0	1	01	01	H0524_054_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	054	0	1	01	01	H0524_054_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	054	0	1	01	01	H0524_054_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	059	0	1	01	01	H0524_059_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H0524	059	0	1	01	01	H0524_059_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	059	0	1	01	01	H0524_059_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													18.00	36.00	54.00				18.00	36.00	36.00				18.00		18.00
H0524	059	0	1	01	01	H0524_059_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	059	0	1	01	01	H0524_059_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	059	0	1	01	01	H0524_059_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	059	0	1	01	01	H0524_059_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	059	0	1	01	01	H0524_059_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	059	0	1	01	01	H0524_059_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	060	0	1	01	01	H0524_060_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	060	0	1	01	01	H0524_060_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	060	0	1	01	01	H0524_060_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													18.00	36.00	54.00				18.00	36.00	36.00				18.00		18.00
H0524	060	0	1	01	01	H0524_060_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	060	0	1	01	01	H0524_060_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	060	0	1	01	01	H0524_060_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	060	0	1	01	01	H0524_060_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	060	0	1	01	01	H0524_060_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	060	0	1	01	01	H0524_060_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	061	0	1	01	01	H0524_061_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													3.00	6.00	9.00				3.00	6.00	6.00				3.00		3.00
H0524	061	0	1	01	01	H0524_061_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	061	0	1	01	01	H0524_061_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H0524	061	0	1	01	01	H0524_061_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	061	0	1	01	01	H0524_061_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	061	0	1	01	01	H0524_061_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	061	0	1	01	01	H0524_061_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	061	0	1	01	01	H0524_061_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	061	0	1	01	01	H0524_061_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	062	0	1	01	01	H0524_062_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													3.00	6.00	9.00				3.00	6.00	6.00				3.00		3.00
H0524	062	0	1	01	01	H0524_062_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	062	0	1	01	01	H0524_062_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H0524	062	0	1	01	01	H0524_062_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	062	0	1	01	01	H0524_062_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	062	0	1	01	01	H0524_062_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	062	0	1	01	01	H0524_062_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	062	0	1	01	01	H0524_062_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	062	0	1	01	01	H0524_062_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	063	0	1	01	01	H0524_063_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	063	0	1	01	01	H0524_063_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	063	0	1	01	01	H0524_063_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													12.00	24.00	36.00				12.00	24.00	24.00				12.00		12.00
H0524	063	0	1	01	01	H0524_063_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	063	0	1	01	01	H0524_063_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	063	0	1	01	01	H0524_063_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	063	0	1	01	01	H0524_063_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	063	0	1	01	01	H0524_063_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	063	0	1	01	01	H0524_063_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	064	0	1	01	01	H0524_064_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H0524	064	0	1	01	01	H0524_064_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	064	0	1	01	01	H0524_064_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													18.00	36.00	54.00				18.00	36.00	36.00				18.00		18.00
H0524	064	0	1	01	01	H0524_064_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	064	0	1	01	01	H0524_064_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	064	0	1	01	01	H0524_064_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	064	0	1	01	01	H0524_064_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	064	0	1	01	01	H0524_064_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	064	0	1	01	01	H0524_064_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	065	0	1	01	01	H0524_065_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00
H0524	065	0	1	01	01	H0524_065_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	065	0	1	01	01	H0524_065_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													18.00	36.00	54.00				18.00	36.00	36.00				18.00		18.00
H0524	065	0	1	01	01	H0524_065_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	36.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	065	0	1	01	01	H0524_065_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	065	0	1	01	01	H0524_065_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	065	0	1	01	01	H0524_065_0	11			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	065	0	1	01	01	H0524_065_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	065	0	1	01	01	H0524_065_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	078	0	1	01	01	H0524_078_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	078	0	1	01	01	H0524_078_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	078	0	1	01	01	H0524_078_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H0524	078	0	1	01	01	H0524_078_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	078	0	1	01	01	H0524_078_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	80.00				35.00		35.00
H0524	078	0	1	01	01	H0524_078_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	078	0	1	01	01	H0524_078_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	078	0	1	01	01	H0524_078_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	078	0	1	01	01	H0524_078_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	081	0	1	01	01	H0524_081_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	081	0	1	01	01	H0524_081_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	081	0	1	01	01	H0524_081_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H0524	081	0	1	01	01	H0524_081_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	081	0	1	01	01	H0524_081_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	081	0	1	01	01	H0524_081_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	081	0	1	01	01	H0524_081_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	081	0	1	01	01	H0524_081_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	081	0	1	01	01	H0524_081_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	082	0	1	01	01	H0524_082_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	082	0	1	01	01	H0524_082_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	082	0	1	01	01	H0524_082_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H0524	082	0	1	01	01	H0524_082_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	082	0	1	01	01	H0524_082_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	082	0	1	01	01	H0524_082_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	082	0	1	01	01	H0524_082_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	082	0	1	01	01	H0524_082_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	082	0	1	01	01	H0524_082_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	083	0	1	01	01	H0524_083_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0524	083	0	1	01	01	H0524_083_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	083	0	1	01	01	H0524_083_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H0524	083	0	1	01	01	H0524_083_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0524	083	0	1	01	01	H0524_083_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H0524	083	0	1	01	01	H0524_083_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	083	0	1	01	01	H0524_083_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0524	083	0	1	01	01	H0524_083_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0524	083	0	1	01	01	H0524_083_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H0543	013	0	1	02	01	H0543_013_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	013	0	1	02	01	H0543_013_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	013	0	1	02	01	H0543_013_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	013	0	1	02	01	H0543_013_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	013	0	1	02	01	H0543_013_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	013	0	1	02	01	H0543_013_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	013	0	1	02	01	H0543_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				512.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	019	0	1	02	01	H0543_019_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	019	0	1	02	01	H0543_019_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	019	0	1	02	01	H0543_019_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	019	0	1	02	01	H0543_019_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	019	0	1	02	01	H0543_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	019	0	1	02	01	H0543_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	019	0	1	02	01	H0543_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				562.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	022	0	1	02	01	H0543_022_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	022	0	1	02	01	H0543_022_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	022	0	1	02	01	H0543_022_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	022	0	1	02	01	H0543_022_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	022	0	1	02	01	H0543_022_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	022	0	1	02	01	H0543_022_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	022	0	1	02	01	H0543_022_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	028	0	1	02	01	H0543_028_0	8			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	3.00		9.00																											9.00						0.00				3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	028	0	1	02	01	H0543_028_0	8			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	3.00		9.00																											9.00						0.00				3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	028	0	1	02	01	H0543_028_0	8			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	028	0	1	02	01	H0543_028_0	8			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	028	0	1	02	01	H0543_028_0	8			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	028	0	1	02	01	H0543_028_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	028	0	1	02	01	H0543_028_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				154.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	035	0	1	02	01	H0543_035_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	035	0	1	02	01	H0543_035_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	035	0	1	02	01	H0543_035_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	035	0	1	02	01	H0543_035_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	035	0	1	02	01	H0543_035_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	035	0	1	02	01	H0543_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	035	0	1	02	01	H0543_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				552.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	036	0	1	02	01	H0543_036_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	036	0	1	02	01	H0543_036_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	036	0	1	02	01	H0543_036_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	036	0	1	02	01	H0543_036_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	036	0	1	02	01	H0543_036_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	036	0	1	02	01	H0543_036_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	036	0	1	02	01	H0543_036_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				627.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	060	0	1	02	01	H0543_060_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	060	0	1	02	01	H0543_060_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	060	0	1	02	01	H0543_060_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	060	0	1	02	01	H0543_060_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	060	0	1	02	01	H0543_060_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	060	0	1	02	01	H0543_060_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	060	0	1	02	01	H0543_060_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				492.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	086	0	1	02	01	H0543_086_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	086	0	1	02	01	H0543_086_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	086	0	1	02	01	H0543_086_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	086	0	1	02	01	H0543_086_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	086	0	1	02	01	H0543_086_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	086	0	1	02	01	H0543_086_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	086	0	1	02	01	H0543_086_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				403.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	089	0	1	02	01	H0543_089_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	089	0	1	02	01	H0543_089_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	089	0	1	02	01	H0543_089_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	089	0	1	02	01	H0543_089_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	089	0	1	02	01	H0543_089_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	089	0	1	02	01	H0543_089_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	089	0	1	02	01	H0543_089_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				543.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	140	0	1	02	01	H0543_140_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	140	0	1	02	01	H0543_140_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	140	0	1	02	01	H0543_140_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	140	0	1	02	01	H0543_140_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	140	0	1	02	01	H0543_140_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	140	0	1	02	01	H0543_140_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	140	0	1	02	01	H0543_140_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				536.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	145	0	1	02	01	H0543_145_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	145	0	1	02	01	H0543_145_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	145	0	1	02	01	H0543_145_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	145	0	1	02	01	H0543_145_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	145	0	1	02	01	H0543_145_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	145	0	1	02	01	H0543_145_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	145	0	1	02	01	H0543_145_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				341.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	146	0	1	02	01	H0543_146_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	146	0	1	02	01	H0543_146_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	146	0	1	02	01	H0543_146_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	146	0	1	02	01	H0543_146_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	146	0	1	02	01	H0543_146_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	146	0	1	02	01	H0543_146_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	146	0	1	02	01	H0543_146_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				586.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	147	0	1	02	01	H0543_147_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	147	0	1	02	01	H0543_147_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	147	0	1	02	01	H0543_147_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	147	0	1	02	01	H0543_147_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	147	0	1	02	01	H0543_147_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	147	0	1	02	01	H0543_147_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	147	0	1	02	01	H0543_147_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	151	0	1	02	01	H0543_151_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	151	0	1	02	01	H0543_151_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	151	0	1	02	01	H0543_151_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	151	0	1	02	01	H0543_151_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	151	0	1	02	01	H0543_151_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	151	0	1	02	01	H0543_151_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	151	0	1	02	01	H0543_151_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				429.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	152	0	1	02	01	H0543_152_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	152	0	1	02	01	H0543_152_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	152	0	1	02	01	H0543_152_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	152	0	1	02	01	H0543_152_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	152	0	1	02	01	H0543_152_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	152	0	1	02	01	H0543_152_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	152	0	1	02	01	H0543_152_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				492.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	164	0	1	02	01	H0543_164_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	164	0	1	02	01	H0543_164_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	164	0	1	02	01	H0543_164_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	164	0	1	02	01	H0543_164_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	164	0	1	02	01	H0543_164_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	164	0	1	02	01	H0543_164_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	164	0	1	02	01	H0543_164_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				676.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	165	0	1	02	01	H0543_165_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	165	0	1	02	01	H0543_165_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	165	0	1	02	01	H0543_165_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	165	0	1	02	01	H0543_165_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	165	0	1	02	01	H0543_165_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	165	0	1	02	01	H0543_165_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	165	0	1	02	01	H0543_165_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				540.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	166	0	1	02	01	H0543_166_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	166	0	1	02	01	H0543_166_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	166	0	1	02	01	H0543_166_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	166	0	1	02	01	H0543_166_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	166	0	1	02	01	H0543_166_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	166	0	1	02	01	H0543_166_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	166	0	1	02	01	H0543_166_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				582.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	167	0	1	02	01	H0543_167_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	167	0	1	02	01	H0543_167_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	167	0	1	02	01	H0543_167_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	167	0	1	02	01	H0543_167_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	167	0	1	02	01	H0543_167_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	167	0	1	02	01	H0543_167_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	167	0	1	02	01	H0543_167_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				592.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	168	0	1	02	01	H0543_168_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	168	0	1	02	01	H0543_168_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	168	0	1	02	01	H0543_168_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	168	0	1	02	01	H0543_168_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	168	0	1	02	01	H0543_168_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	168	0	1	02	01	H0543_168_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	168	0	1	02	01	H0543_168_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				509.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	169	0	1	02	01	H0543_169_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	169	0	1	02	01	H0543_169_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	169	0	1	02	01	H0543_169_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	169	0	1	02	01	H0543_169_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	169	0	1	02	01	H0543_169_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	169	0	1	02	01	H0543_169_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	169	0	1	02	01	H0543_169_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				467.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	170	0	1	02	01	H0543_170_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	170	0	1	02	01	H0543_170_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	170	0	1	02	01	H0543_170_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	170	0	1	02	01	H0543_170_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	170	0	1	02	01	H0543_170_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	170	0	1	02	01	H0543_170_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	170	0	1	02	01	H0543_170_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				584.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	176	0	1	02	01	H0543_176_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	176	0	1	02	01	H0543_176_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	176	0	1	02	01	H0543_176_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	176	0	1	02	01	H0543_176_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	176	0	1	02	01	H0543_176_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	176	0	1	02	01	H0543_176_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	176	0	1	02	01	H0543_176_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				722.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	188	0	1	02	01	H0543_188_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	188	0	1	02	01	H0543_188_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	188	0	1	02	01	H0543_188_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	188	0	1	02	01	H0543_188_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	188	0	1	02	01	H0543_188_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	188	0	1	02	01	H0543_188_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	188	0	1	02	01	H0543_188_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				550.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	189	0	1	02	01	H0543_189_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	189	0	1	02	01	H0543_189_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	189	0	1	02	01	H0543_189_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	189	0	1	02	01	H0543_189_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	189	0	1	02	01	H0543_189_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	189	0	1	02	01	H0543_189_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	189	0	1	02	01	H0543_189_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				556.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	191	0	1	02	01	H0543_191_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	191	0	1	02	01	H0543_191_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	191	0	1	02	01	H0543_191_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	191	0	1	02	01	H0543_191_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	191	0	1	02	01	H0543_191_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	191	0	1	02	01	H0543_191_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	191	0	1	02	01	H0543_191_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				651.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	193	0	1	02	01	H0543_193_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	193	0	1	02	01	H0543_193_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	193	0	1	02	01	H0543_193_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	193	0	1	02	01	H0543_193_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	193	0	1	02	01	H0543_193_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	193	0	1	02	01	H0543_193_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	193	0	1	02	01	H0543_193_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				525.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	195	0	1	02	01	H0543_195_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	195	0	1	02	01	H0543_195_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	195	0	1	02	01	H0543_195_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	195	0	1	02	01	H0543_195_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	195	0	1	02	01	H0543_195_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	195	0	1	02	01	H0543_195_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	195	0	1	02	01	H0543_195_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				416.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	196	0	1	02	01	H0543_196_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	196	0	1	02	01	H0543_196_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	196	0	1	02	01	H0543_196_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	196	0	1	02	01	H0543_196_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	196	0	1	02	01	H0543_196_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	196	0	1	02	01	H0543_196_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	196	0	1	02	01	H0543_196_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				661.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	204	0	1	02	01	H0543_204_0	6			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	204	0	1	02	01	H0543_204_0	6			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	204	0	1	02	01	H0543_204_0	6			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	204	0	1	02	01	H0543_204_0	6			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	204	0	1	02	01	H0543_204_0	6			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H0543	204	0	1	02	01	H0543_204_0	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H0543	204	0	1	02	01	H0543_204_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											545.00	33						614.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	209	0	1	02	01	H0543_209_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	209	0	1	02	01	H0543_209_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	209	0	1	02	01	H0543_209_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	209	0	1	02	01	H0543_209_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	209	0	1	02	01	H0543_209_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	209	0	1	02	01	H0543_209_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	209	0	1	02	01	H0543_209_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				660.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	210	0	1	02	01	H0543_210_0	8			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	210	0	1	02	01	H0543_210_0	8			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	210	0	1	02	01	H0543_210_0	8			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	210	0	1	02	01	H0543_210_0	8			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	210	0	1	02	01	H0543_210_0	8			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	210	0	1	02	01	H0543_210_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	210	0	1	02	01	H0543_210_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				561.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	214	0	1	02	01	H0543_214_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	214	0	1	02	01	H0543_214_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	214	0	1	02	01	H0543_214_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	214	0	1	02	01	H0543_214_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	214	0	1	02	01	H0543_214_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	214	0	1	02	01	H0543_214_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	214	0	1	02	01	H0543_214_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				537.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	215	0	1	02	01	H0543_215_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	215	0	1	02	01	H0543_215_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	215	0	1	02	01	H0543_215_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	215	0	1	02	01	H0543_215_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	215	0	1	02	01	H0543_215_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	215	0	1	02	01	H0543_215_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	215	0	1	02	01	H0543_215_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				413.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	216	0	1	02	01	H0543_216_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	216	0	1	02	01	H0543_216_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	216	0	1	02	01	H0543_216_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	216	0	1	02	01	H0543_216_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	216	0	1	02	01	H0543_216_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	216	0	1	02	01	H0543_216_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	216	0	1	02	01	H0543_216_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				675.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	217	0	1	02	01	H0543_217_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	217	0	1	02	01	H0543_217_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	217	0	1	02	01	H0543_217_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	217	0	1	02	01	H0543_217_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	217	0	1	02	01	H0543_217_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	217	0	1	02	01	H0543_217_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	217	0	1	02	01	H0543_217_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				529.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	218	0	1	02	01	H0543_218_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	218	0	1	02	01	H0543_218_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	218	0	1	02	01	H0543_218_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	218	0	1	02	01	H0543_218_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	218	0	1	02	01	H0543_218_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	218	0	1	02	01	H0543_218_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	218	0	1	02	01	H0543_218_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				580.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	219	0	1	02	01	H0543_219_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	219	0	1	02	01	H0543_219_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	219	0	1	02	01	H0543_219_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	219	0	1	02	01	H0543_219_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	219	0	1	02	01	H0543_219_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	219	0	1	02	01	H0543_219_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	219	0	1	02	01	H0543_219_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				499.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	220	0	1	02	01	H0543_220_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	220	0	1	02	01	H0543_220_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	220	0	1	02	01	H0543_220_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	220	0	1	02	01	H0543_220_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	220	0	1	02	01	H0543_220_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	220	0	1	02	01	H0543_220_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	220	0	1	02	01	H0543_220_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				553.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	221	0	1	02	01	H0543_221_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	221	0	1	02	01	H0543_221_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	221	0	1	02	01	H0543_221_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	221	0	1	02	01	H0543_221_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	221	0	1	02	01	H0543_221_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	35.00		105.00																											105.00						95.00				35.00				35.00		1.16						1.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	221	0	1	02	01	H0543_221_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	221	0	1	02	01	H0543_221_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				640.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	222	0	1	02	01	H0543_222_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	222	0	1	02	01	H0543_222_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	222	0	1	02	01	H0543_222_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	222	0	1	02	01	H0543_222_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	222	0	1	02	01	H0543_222_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	222	0	1	02	01	H0543_222_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	222	0	1	02	01	H0543_222_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				678.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	223	0	1	02	01	H0543_223_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	223	0	1	02	01	H0543_223_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	223	0	1	02	01	H0543_223_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	223	0	1	02	01	H0543_223_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	223	0	1	02	01	H0543_223_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	223	0	1	02	01	H0543_223_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	223	0	1	02	01	H0543_223_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				672.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	224	0	1	02	01	H0543_224_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	224	0	1	02	01	H0543_224_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	224	0	1	02	01	H0543_224_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	224	0	1	02	01	H0543_224_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	224	0	1	02	01	H0543_224_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0543	224	0	1	02	01	H0543_224_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	224	0	1	02	01	H0543_224_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				490.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	225	0	1	02	01	H0543_225_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	225	0	1	02	01	H0543_225_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	225	0	1	02	01	H0543_225_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	225	0	1	02	01	H0543_225_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	225	0	1	02	01	H0543_225_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	225	0	1	02	01	H0543_225_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	225	0	1	02	01	H0543_225_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	226	0	1	02	01	H0543_226_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	226	0	1	02	01	H0543_226_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	226	0	1	02	01	H0543_226_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	226	0	1	02	01	H0543_226_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	226	0	1	02	01	H0543_226_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	226	0	1	02	01	H0543_226_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	226	0	1	02	01	H0543_226_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				540.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	227	0	1	02	01	H0543_227_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	227	0	1	02	01	H0543_227_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	227	0	1	02	01	H0543_227_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	227	0	1	02	01	H0543_227_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	227	0	1	02	01	H0543_227_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	227	0	1	02	01	H0543_227_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	227	0	1	02	01	H0543_227_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				509.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	228	0	1	02	01	H0543_228_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	228	0	1	02	01	H0543_228_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	228	0	1	02	01	H0543_228_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	228	0	1	02	01	H0543_228_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	228	0	1	02	01	H0543_228_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	228	0	1	02	01	H0543_228_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	228	0	1	02	01	H0543_228_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				675.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	229	0	1	02	01	H0543_229_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	229	0	1	02	01	H0543_229_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	229	0	1	02	01	H0543_229_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	229	0	1	02	01	H0543_229_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	229	0	1	02	01	H0543_229_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	229	0	1	02	01	H0543_229_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	229	0	1	02	01	H0543_229_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				276.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	230	0	1	02	01	H0543_230_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	230	0	1	02	01	H0543_230_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	230	0	1	02	01	H0543_230_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	230	0	1	02	01	H0543_230_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	230	0	1	02	01	H0543_230_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	230	0	1	02	01	H0543_230_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	230	0	1	02	01	H0543_230_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				334.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	231	0	1	02	01	H0543_231_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	231	0	1	02	01	H0543_231_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	231	0	1	02	01	H0543_231_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	231	0	1	02	01	H0543_231_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	231	0	1	02	01	H0543_231_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	231	0	1	02	01	H0543_231_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	231	0	1	02	01	H0543_231_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				442.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	232	0	1	02	01	H0543_232_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	232	0	1	02	01	H0543_232_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	232	0	1	02	01	H0543_232_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	232	0	1	02	01	H0543_232_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	232	0	1	02	01	H0543_232_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	232	0	1	02	01	H0543_232_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	232	0	1	02	01	H0543_232_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				669.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	234	0	1	02	01	H0543_234_0	8			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	234	0	1	02	01	H0543_234_0	8			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	234	0	1	02	01	H0543_234_0	8			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	234	0	1	02	01	H0543_234_0	8			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	234	0	1	02	01	H0543_234_0	8			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	234	0	1	02	01	H0543_234_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	234	0	1	02	01	H0543_234_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				627.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	235	0	1	02	01	H0543_235_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	235	0	1	02	01	H0543_235_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	235	0	1	02	01	H0543_235_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	235	0	1	02	01	H0543_235_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	235	0	1	02	01	H0543_235_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	235	0	1	02	01	H0543_235_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	235	0	1	02	01	H0543_235_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				537.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	236	0	1	02	01	H0543_236_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	236	0	1	02	01	H0543_236_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	236	0	1	02	01	H0543_236_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	236	0	1	02	01	H0543_236_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	236	0	1	02	01	H0543_236_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	236	0	1	02	01	H0543_236_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	236	0	1	02	01	H0543_236_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				554.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	237	0	1	02	01	H0543_237_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	237	0	1	02	01	H0543_237_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	237	0	1	02	01	H0543_237_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	237	0	1	02	01	H0543_237_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	237	0	1	02	01	H0543_237_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	237	0	1	02	01	H0543_237_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	237	0	1	02	01	H0543_237_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				498.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	238	0	1	02	01	H0543_238_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	238	0	1	02	01	H0543_238_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	238	0	1	02	01	H0543_238_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	238	0	1	02	01	H0543_238_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0543	238	0	1	02	01	H0543_238_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	238	0	1	02	01	H0543_238_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	238	0	1	02	01	H0543_238_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				628.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	248	0	1	02	01	H0543_248_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	248	0	1	02	01	H0543_248_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0543	248	0	1	02	01	H0543_248_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0543	248	0	1	02	01	H0543_248_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0543	248	0	1	02	01	H0543_248_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H0543	248	0	1	02	01	H0543_248_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0543	248	0	1	02	01	H0543_248_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				493.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	002	0	1	01	01	H0544_002_0	13			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	002	0	1	01	01	H0544_002_0	13			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	002	0	1	01	01	H0544_002_0	13			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	002	0	1	01	01	H0544_002_0	13			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	002	0	1	01	01	H0544_002_0	13			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					30.00	60.00	90.00					30.00	60.00	60.00																35.00				35.00			1.17	1.00	1.00			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30		30
H0544	002	0	1	01	01	H0544_002_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	002	0	1	01	01	H0544_002_0	13			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	002	0	1	01	01	H0544_002_0	13			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	002	0	1	01	01	H0544_002_0	13			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	004	0	1	01	01	H0544_004_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	004	0	1	01	01	H0544_004_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	004	0	1	01	01	H0544_004_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	004	0	1	01	01	H0544_004_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	004	0	1	01	01	H0544_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								30.00	60.00	90.00					30.00	60.00	90.00					30.00	60.00	60.00																30.00				30.00			1.00	1.00	1.00			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H0544	004	0	1	01	01	H0544_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	004	0	1	01	01	H0544_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	004	0	1	01	01	H0544_004_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	004	0	1	01	01	H0544_004_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	005	0	1	01	01	H0544_005_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	005	0	1	01	01	H0544_005_0	9			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	005	0	1	01	01	H0544_005_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	005	0	1	01	01	H0544_005_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	005	0	1	01	01	H0544_005_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	35.00	70.00	105.00																			35.00	70.00	70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H0544	005	0	1	01	01	H0544_005_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H0544	005	0	1	01	01	H0544_005_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	005	0	1	01	01	H0544_005_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H0544	005	0	1	01	01	H0544_005_0	9			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	007	0	1	01	01	H0544_007_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					5.00	10.00	15.00					0.00	0.00	0.00																5.00				5.00			0.17	0.17	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	007	0	1	01	01	H0544_007_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					14.50	29.00	43.50					0.00	0.00	0.00																14.50				14.50			0.48	0.48	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	007	0	1	01	01	H0544_007_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					45.00	90.00	135.00					45.00	90.00	90.00																45.00				45.00			1.50	1.50	1.50			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	007	0	1	01	01	H0544_007_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	007	0	1	01	01	H0544_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	007	0	1	01	01	H0544_007_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H0544	007	0	1	01	01	H0544_007_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	008	0	1	01	01	H0544_008_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	008	0	1	01	01	H0544_008_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	008	0	1	01	01	H0544_008_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	008	0	1	01	01	H0544_008_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	008	0	1	01	01	H0544_008_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	008	0	1	01	01	H0544_008_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	008	0	1	01	01	H0544_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	008	0	1	01	01	H0544_008_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	008	0	1	01	01	H0544_008_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	010	0	1	01	01	H0544_010_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	010	0	1	01	01	H0544_010_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	010	0	1	01	01	H0544_010_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	010	0	1	01	01	H0544_010_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	010	0	1	01	01	H0544_010_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	010	0	1	01	01	H0544_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	010	0	1	01	01	H0544_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	010	0	1	01	01	H0544_010_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	010	0	1	01	01	H0544_010_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	014	0	1	01	01	H0544_014_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	014	0	1	01	01	H0544_014_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	014	0	1	01	01	H0544_014_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	014	0	1	01	01	H0544_014_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	014	0	1	01	01	H0544_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					30.00	60.00	90.00					30.00	60.00	60.00																35.00				35.00			1.17	1.00	1.00			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H0544	014	0	1	01	01	H0544_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	014	0	1	01	01	H0544_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	014	0	1	01	01	H0544_014_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	014	0	1	01	01	H0544_014_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	015	0	1	01	01	H0544_015_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	015	0	1	01	01	H0544_015_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	015	0	1	01	01	H0544_015_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	015	0	1	01	01	H0544_015_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	015	0	1	01	01	H0544_015_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					30.00	60.00	90.00					30.00	60.00	60.00																35.00				35.00			1.17	1.00	1.00			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H0544	015	0	1	01	01	H0544_015_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	015	0	1	01	01	H0544_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	015	0	1	01	01	H0544_015_0	6			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	015	0	1	01	01	H0544_015_0	6			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	019	0	1	01	01	H0544_019_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	019	0	1	01	01	H0544_019_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	019	0	1	01	01	H0544_019_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	019	0	1	01	01	H0544_019_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	019	0	1	01	01	H0544_019_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	019	0	1	01	01	H0544_019_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	019	0	1	01	01	H0544_019_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	019	0	1	01	01	H0544_019_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	019	0	1	01	01	H0544_019_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	020	0	1	01	01	H0544_020_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	020	0	1	01	01	H0544_020_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	020	0	1	01	01	H0544_020_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	020	0	1	01	01	H0544_020_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.50	29.00	43.50					9.50	19.00	28.50					0.00	0.00	0.00																14.50				14.50			0.48	0.32	0.00			0.43	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	020	0	1	01	01	H0544_020_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	020	0	1	01	01	H0544_020_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	020	0	1	01	01	H0544_020_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	020	0	1	01	01	H0544_020_0	6			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H0544	020	0	1	01	01	H0544_020_0	6			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	056	0	1	01	01	H0544_056_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	056	0	1	01	01	H0544_056_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	056	0	1	01	01	H0544_056_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	056	0	1	01	01	H0544_056_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	056	0	1	01	01	H0544_056_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	056	0	1	01	01	H0544_056_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	056	0	1	01	01	H0544_056_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	058	0	1	01	01	H0544_058_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	058	0	1	01	01	H0544_058_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0544	058	0	1	01	01	H0544_058_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	058	0	1	01	01	H0544_058_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	058	0	1	01	01	H0544_058_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	058	0	1	01	01	H0544_058_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	058	0	1	01	01	H0544_058_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	061	0	1	01	01	H0544_061_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	061	0	1	01	01	H0544_061_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	061	0	1	01	01	H0544_061_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	061	0	1	01	01	H0544_061_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	061	0	1	01	01	H0544_061_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	061	0	1	01	01	H0544_061_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	062	0	1	01	01	H0544_062_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	062	0	1	01	01	H0544_062_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	062	0	1	01	01	H0544_062_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	062	0	1	01	01	H0544_062_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	062	0	1	01	01	H0544_062_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	062	0	1	01	01	H0544_062_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	063	0	1	01	01	H0544_063_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	063	0	1	01	01	H0544_063_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	063	0	1	01	01	H0544_063_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.00	28.00	42.00					5.00	10.00	15.00					0.00	0.00	0.00																14.00				14.00			0.47	0.17	0.00			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	063	0	1	01	01	H0544_063_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	063	0	1	01	01	H0544_063_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	063	0	1	01	01	H0544_063_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	064	0	1	01	01	H0544_064_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	064	0	1	01	01	H0544_064_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	064	0	1	01	01	H0544_064_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	064	0	1	01	01	H0544_064_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	064	0	1	01	01	H0544_064_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	064	0	1	01	01	H0544_064_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	064	0	1	01	01	H0544_064_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	065	0	1	01	01	H0544_065_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	065	0	1	01	01	H0544_065_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.00	24.00	36.00					7.00	14.00	21.00					0.00	0.00	0.00																12.00				12.00			0.40	0.23	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	065	0	1	01	01	H0544_065_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	065	0	1	01	01	H0544_065_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	065	0	1	01	01	H0544_065_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	065	0	1	01	01	H0544_065_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	065	0	1	01	01	H0544_065_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	066	0	1	01	01	H0544_066_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	066	0	1	01	01	H0544_066_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0544	066	0	1	01	01	H0544_066_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	066	0	1	01	01	H0544_066_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	066	0	1	01	01	H0544_066_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	066	0	1	01	01	H0544_066_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	069	0	1	01	01	H0544_069_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	069	0	1	01	01	H0544_069_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0544	069	0	1	01	01	H0544_069_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	069	0	1	01	01	H0544_069_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	069	0	1	01	01	H0544_069_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	069	0	1	01	01	H0544_069_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	091	0	1	01	01	H0544_091_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	091	0	1	01	01	H0544_091_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	091	0	1	01	01	H0544_091_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.00	24.00	36.00					7.00	14.00	21.00					0.00	0.00	0.00																12.00				12.00			0.40	0.23	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	091	0	1	01	01	H0544_091_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	091	0	1	01	01	H0544_091_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	091	0	1	01	01	H0544_091_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	095	0	1	01	01	H0544_095_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	095	0	1	01	01	H0544_095_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	095	0	1	01	01	H0544_095_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	095	0	1	01	01	H0544_095_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	095	0	1	01	01	H0544_095_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	095	0	1	01	01	H0544_095_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0544	095	0	1	01	01	H0544_095_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0544	096	0	1	01	01	H0544_096_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	096	0	1	01	01	H0544_096_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	096	0	1	01	01	H0544_096_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	096	0	1	01	01	H0544_096_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	096	0	1	01	01	H0544_096_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	096	0	1	01	01	H0544_096_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	098	0	1	01	01	H0544_098_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	098	0	1	01	01	H0544_098_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	098	0	1	01	01	H0544_098_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	098	0	1	01	01	H0544_098_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	098	0	1	01	01	H0544_098_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	098	0	1	01	01	H0544_098_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	108	0	1	01	01	H0544_108_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	108	0	1	01	01	H0544_108_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0544	108	0	1	01	01	H0544_108_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	108	0	1	01	01	H0544_108_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H0544	108	0	1	01	01	H0544_108_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	108	0	1	01	01	H0544_108_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	127	0	1	01	01	H0544_127_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	127	0	1	01	01	H0544_127_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0544	127	0	1	01	01	H0544_127_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	127	0	1	01	01	H0544_127_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0544	127	0	1	01	01	H0544_127_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0544	127	0	1	01	01	H0544_127_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0562	009	0	1	01	01	H0562_009_0	15			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	009	0	1	01	01	H0562_009_0	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	009	0	1	01	01	H0562_009_0	15			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	009	0	1	01	01	H0562_009_0	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.66	43	43	43				97.66	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	009	0	1	01	01	H0562_009_0	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	009	0	1	01	01	H0562_009_0	15			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	012	0	1	01	01	H0562_012_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	012	0	1	01	01	H0562_012_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	012	0	1	01	01	H0562_012_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	012	0	1	01	01	H0562_012_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.42	41	41	41				99.42	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	012	0	1	01	01	H0562_012_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	012	0	1	01	01	H0562_012_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	039	0	1	01	01	H0562_039_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	0.00				15.00				15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	039	0	1	01	01	H0562_039_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	039	0	1	01	01	H0562_039_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	039	0	1	01	01	H0562_039_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											74.68	50	50	50				74.68	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	039	0	1	01	01	H0562_039_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	039	0	1	01	01	H0562_039_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	079	0	1	01	01	H0562_079_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	079	0	1	01	01	H0562_079_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	079	0	1	01	01	H0562_079_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	079	0	1	01	01	H0562_079_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.91	50	50	50				88.91	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	079	0	1	01	01	H0562_079_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	079	0	1	01	01	H0562_079_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	092	0	1	01	01	H0562_092_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	092	0	1	01	01	H0562_092_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					8.00	16.00	24.00											15.00	30.00	45.00				8.00	16.00	0.00				15.00				15.00			0.50	0.27		0.50	0.27	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	092	0	1	01	01	H0562_092_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	092	0	1	01	01	H0562_092_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.48	37	37	37				97.48	37	37	37										37	37	37				37	37	37			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	092	0	1	01	01	H0562_092_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	092	0	1	01	01	H0562_092_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H0562	097	0	1	01	01	H0562_097_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	097	0	1	01	01	H0562_097_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	097	0	1	01	01	H0562_097_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	097	0	1	01	01	H0562_097_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.27	41	41	41				99.27	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	097	0	1	01	01	H0562_097_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	097	0	1	01	01	H0562_097_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	125	0	1	01	01	H0562_125_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	125	0	1	01	01	H0562_125_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0562	125	0	1	01	01	H0562_125_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	125	0	1	01	01	H0562_125_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	125	0	1	01	01	H0562_125_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.13	39	39	39				99.13	39	39	39										39	39	39				39	39	39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	125	0	1	01	01	H0562_125_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	125	0	1	01	01	H0562_125_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	125	0	1	01	01	H0562_125_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0562	126	0	1	01	01	H0562_126_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	126	0	1	01	01	H0562_126_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0562	126	0	1	01	01	H0562_126_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	0.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	126	0	1	01	01	H0562_126_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	126	0	1	01	01	H0562_126_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.37	50	50	50				88.37	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	126	0	1	01	01	H0562_126_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	126	0	1	01	01	H0562_126_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	126	0	1	01	01	H0562_126_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0562	128	0	1	01	01	H0562_128_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	128	0	1	01	01	H0562_128_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	128	0	1	01	01	H0562_128_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	128	0	1	01	01	H0562_128_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.64	50	50	50				84.64	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	128	0	1	01	01	H0562_128_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	128	0	1	01	01	H0562_128_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	1	1	01	01	H0562_130_1	15			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	1	1	01	01	H0562_130_1	15			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0562	130	1	1	01	01	H0562_130_1	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	1	1	01	01	H0562_130_1	15			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	130	1	1	01	01	H0562_130_1	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.51	44	44	44				98.51	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	130	1	1	01	01	H0562_130_1	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	130	1	1	01	01	H0562_130_1	15			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	1	1	01	01	H0562_130_1	15			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0562	130	2	1	01	01	H0562_130_2	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	2	1	01	01	H0562_130_2	16			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0562	130	2	1	01	01	H0562_130_2	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	2	1	01	01	H0562_130_2	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0562	130	2	1	01	01	H0562_130_2	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.51	44	44	44				98.51	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0562	130	2	1	01	01	H0562_130_2	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0562	130	2	1	01	01	H0562_130_2	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0562	130	2	1	01	01	H0562_130_2	16			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0571	001	0	1	01	01	H0571_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10	100		1				30	60	90	1	2			90					14	31								3.00	6.00	9.00					0.00	0.00	0.00							6.00																	3.00			3.00			0.10	0.00				0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0571	001	0	1	01	01	H0571_001_0	7			Generic	4	01	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								7.00	14.00	21.00					7.00	14.00	14.00							14.00																	7.00			7.00			0.23	0.23				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	7.00	14.00	14.00			14.00				7.00		7.00
H0571	001	0	1	01	01	H0571_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								40.00	80.00	120.00					40.00	80.00	80.00							80.00																	40.00			40.00			1.33	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	80.00			80.00				35.00		35.00
H0571	001	0	1	01	01	H0571_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								60.00	120.00	180.00					60.00	120.00	120.00							120.00																	60.00			60.00			2.00	2.00				1.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0571	001	0	1	01	01	H0571_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											583.67	33						779.94	33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0571	007	0	1	01	01	H0571_007_0	7			Preferred Generic	4	01	1	2	1	1		111	10	100		1				30	60	90	1	2			90					14	31								5.00	10.00	15.00					0.00	0.00	0.00							10.00																	5.00			5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0571	007	0	1	01	01	H0571_007_0	7			Generic	4	01	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								12.00	24.00	36.00					12.00	24.00	24.00							24.00																	12.00			12.00			0.40	0.40				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	12.00	24.00	24.00			24.00				12.00		12.00
H0571	007	0	1	01	01	H0571_007_0	7			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								47.00	94.00	141.00					47.00	94.00	94.00							94.00																	47.00			47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	94.00			94.00				35.00		35.00
H0571	007	0	1	01	01	H0571_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								100.00	200.00	300.00					100.00	200.00	200.00							200.00																	100.00			100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0571	007	0	1	01	01	H0571_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											959.99	31						998.91	31						31																		31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	007	0	1	02	01	H0609_007_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	007	0	1	02	01	H0609_007_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	007	0	1	02	01	H0609_007_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	007	0	1	02	01	H0609_007_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	007	0	1	02	01	H0609_007_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	007	0	1	02	01	H0609_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	007	0	1	02	01	H0609_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				571.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	012	0	1	02	01	H0609_012_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	012	0	1	02	01	H0609_012_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	012	0	1	02	01	H0609_012_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	012	0	1	02	01	H0609_012_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	012	0	1	02	01	H0609_012_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	012	0	1	02	01	H0609_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	012	0	1	02	01	H0609_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				589.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	025	0	1	02	01	H0609_025_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	025	0	1	02	01	H0609_025_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	025	0	1	02	01	H0609_025_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	025	0	1	02	01	H0609_025_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	025	0	1	02	01	H0609_025_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	025	0	1	02	01	H0609_025_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	025	0	1	02	01	H0609_025_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				496.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	026	0	1	02	01	H0609_026_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	026	0	1	02	01	H0609_026_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	026	0	1	02	01	H0609_026_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	026	0	1	02	01	H0609_026_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	026	0	1	02	01	H0609_026_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	026	0	1	02	01	H0609_026_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	026	0	1	02	01	H0609_026_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				553.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	027	0	1	02	01	H0609_027_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	027	0	1	02	01	H0609_027_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	027	0	1	02	01	H0609_027_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	027	0	1	02	01	H0609_027_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	027	0	1	02	01	H0609_027_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	027	0	1	02	01	H0609_027_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	027	0	1	02	01	H0609_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				550.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	028	0	1	02	01	H0609_028_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	028	0	1	02	01	H0609_028_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	028	0	1	02	01	H0609_028_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	028	0	1	02	01	H0609_028_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	028	0	1	02	01	H0609_028_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	028	0	1	02	01	H0609_028_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	028	0	1	02	01	H0609_028_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				463.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	031	0	1	02	01	H0609_031_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	031	0	1	02	01	H0609_031_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	031	0	1	02	01	H0609_031_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	031	0	1	02	01	H0609_031_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	031	0	1	02	01	H0609_031_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	031	0	1	02	01	H0609_031_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	031	0	1	02	01	H0609_031_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				652.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	032	0	1	02	01	H0609_032_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	032	0	1	02	01	H0609_032_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	032	0	1	02	01	H0609_032_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	032	0	1	02	01	H0609_032_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	032	0	1	02	01	H0609_032_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	032	0	1	02	01	H0609_032_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	032	0	1	02	01	H0609_032_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				633.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	033	0	1	02	01	H0609_033_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	033	0	1	02	01	H0609_033_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	033	0	1	02	01	H0609_033_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	033	0	1	02	01	H0609_033_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	033	0	1	02	01	H0609_033_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	033	0	1	02	01	H0609_033_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	033	0	1	02	01	H0609_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				613.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	034	1	1	02	01	H0609_034_1	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	034	1	1	02	01	H0609_034_1	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	034	1	1	02	01	H0609_034_1	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	034	1	1	02	01	H0609_034_1	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	034	1	1	02	01	H0609_034_1	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	034	1	1	02	01	H0609_034_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	034	1	1	02	01	H0609_034_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				490.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	034	2	1	02	01	H0609_034_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	034	2	1	02	01	H0609_034_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	034	2	1	02	01	H0609_034_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	034	2	1	02	01	H0609_034_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	034	2	1	02	01	H0609_034_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	034	2	1	02	01	H0609_034_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	034	2	1	02	01	H0609_034_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				490.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	036	1	1	02	01	H0609_036_1	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	036	1	1	02	01	H0609_036_1	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	036	1	1	02	01	H0609_036_1	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	036	1	1	02	01	H0609_036_1	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	036	1	1	02	01	H0609_036_1	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	036	1	1	02	01	H0609_036_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	036	1	1	02	01	H0609_036_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				543.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	036	2	1	02	01	H0609_036_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	036	2	1	02	01	H0609_036_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	036	2	1	02	01	H0609_036_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	036	2	1	02	01	H0609_036_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	036	2	1	02	01	H0609_036_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	036	2	1	02	01	H0609_036_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	036	2	1	02	01	H0609_036_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				543.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	037	0	1	02	01	H0609_037_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	037	0	1	02	01	H0609_037_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	037	0	1	02	01	H0609_037_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	037	0	1	02	01	H0609_037_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	037	0	1	02	01	H0609_037_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	037	0	1	02	01	H0609_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	037	0	1	02	01	H0609_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				474.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	038	0	1	02	01	H0609_038_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	038	0	1	02	01	H0609_038_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	038	0	1	02	01	H0609_038_0	7			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	038	0	1	02	01	H0609_038_0	7			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	038	0	1	02	01	H0609_038_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H0609	038	0	1	02	01	H0609_038_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H0609	038	0	1	02	01	H0609_038_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											578.00	33						700.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	040	0	1	02	01	H0609_040_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	040	0	1	02	01	H0609_040_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	040	0	1	02	01	H0609_040_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	040	0	1	02	01	H0609_040_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	040	0	1	02	01	H0609_040_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	040	0	1	02	01	H0609_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	040	0	1	02	01	H0609_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				583.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	042	0	1	02	01	H0609_042_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	042	0	1	02	01	H0609_042_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	042	0	1	02	01	H0609_042_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	042	0	1	02	01	H0609_042_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	042	0	1	02	01	H0609_042_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	042	0	1	02	01	H0609_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	042	0	1	02	01	H0609_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				561.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	043	0	1	02	01	H0609_043_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	043	0	1	02	01	H0609_043_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	043	0	1	02	01	H0609_043_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	043	0	1	02	01	H0609_043_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	043	0	1	02	01	H0609_043_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	043	0	1	02	01	H0609_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	043	0	1	02	01	H0609_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				470.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	044	0	1	02	01	H0609_044_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	044	0	1	02	01	H0609_044_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	044	0	1	02	01	H0609_044_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	044	0	1	02	01	H0609_044_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	044	0	1	02	01	H0609_044_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	044	0	1	02	01	H0609_044_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	044	0	1	02	01	H0609_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				577.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	045	0	1	02	01	H0609_045_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	045	0	1	02	01	H0609_045_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	045	0	1	02	01	H0609_045_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	045	0	1	02	01	H0609_045_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	045	0	1	02	01	H0609_045_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	045	0	1	02	01	H0609_045_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	045	0	1	02	01	H0609_045_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				587.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	046	0	1	02	01	H0609_046_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	046	0	1	02	01	H0609_046_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	046	0	1	02	01	H0609_046_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	046	0	1	02	01	H0609_046_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	046	0	1	02	01	H0609_046_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	046	0	1	02	01	H0609_046_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	046	0	1	02	01	H0609_046_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				805.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	047	0	1	02	01	H0609_047_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	047	0	1	02	01	H0609_047_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	047	0	1	02	01	H0609_047_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	047	0	1	02	01	H0609_047_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	047	0	1	02	01	H0609_047_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	047	0	1	02	01	H0609_047_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	047	0	1	02	01	H0609_047_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				494.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	048	0	1	02	01	H0609_048_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	048	0	1	02	01	H0609_048_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	048	0	1	02	01	H0609_048_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	048	0	1	02	01	H0609_048_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	048	0	1	02	01	H0609_048_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	048	0	1	02	01	H0609_048_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	048	0	1	02	01	H0609_048_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				500.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	049	0	1	02	01	H0609_049_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	049	0	1	02	01	H0609_049_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	049	0	1	02	01	H0609_049_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	049	0	1	02	01	H0609_049_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0609	049	0	1	02	01	H0609_049_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	049	0	1	02	01	H0609_049_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	049	0	1	02	01	H0609_049_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				471.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	050	0	1	02	01	H0609_050_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	050	0	1	02	01	H0609_050_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	050	0	1	02	01	H0609_050_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	050	0	1	02	01	H0609_050_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	050	0	1	02	01	H0609_050_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	050	0	1	02	01	H0609_050_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	050	0	1	02	01	H0609_050_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				577.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	051	0	1	02	01	H0609_051_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	051	0	1	02	01	H0609_051_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	051	0	1	02	01	H0609_051_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	7.00		21.00																											21.00						0.00				7.00				7.00		0.23						0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	051	0	1	02	01	H0609_051_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	7.00		21.00																											21.00						0.00				7.00				7.00		0.23						0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	051	0	1	02	01	H0609_051_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	051	0	1	02	01	H0609_051_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	051	0	1	02	01	H0609_051_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				495.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	054	0	1	02	01	H0609_054_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	054	0	1	02	01	H0609_054_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	054	0	1	02	01	H0609_054_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	054	0	1	02	01	H0609_054_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	054	0	1	02	01	H0609_054_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	054	0	1	02	01	H0609_054_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	054	0	1	02	01	H0609_054_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				263.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	058	0	1	02	01	H0609_058_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	058	0	1	02	01	H0609_058_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	058	0	1	02	01	H0609_058_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	058	0	1	02	01	H0609_058_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	058	0	1	02	01	H0609_058_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	058	0	1	02	01	H0609_058_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	058	0	1	02	01	H0609_058_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				561.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	059	0	1	02	01	H0609_059_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	059	0	1	02	01	H0609_059_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	059	0	1	02	01	H0609_059_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	059	0	1	02	01	H0609_059_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	059	0	1	02	01	H0609_059_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	059	0	1	02	01	H0609_059_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	059	0	1	02	01	H0609_059_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				487.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	060	0	1	02	01	H0609_060_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	060	0	1	02	01	H0609_060_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	060	0	1	02	01	H0609_060_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	060	0	1	02	01	H0609_060_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	060	0	1	02	01	H0609_060_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	060	0	1	02	01	H0609_060_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	060	0	1	02	01	H0609_060_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				590.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	061	0	1	02	01	H0609_061_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	061	0	1	02	01	H0609_061_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	061	0	1	02	01	H0609_061_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	061	0	1	02	01	H0609_061_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	061	0	1	02	01	H0609_061_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	061	0	1	02	01	H0609_061_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	061	0	1	02	01	H0609_061_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				550.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	062	0	1	02	01	H0609_062_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	062	0	1	02	01	H0609_062_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	062	0	1	02	01	H0609_062_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	062	0	1	02	01	H0609_062_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	062	0	1	02	01	H0609_062_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H0609	062	0	1	02	01	H0609_062_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	062	0	1	02	01	H0609_062_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				473.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	063	0	1	02	01	H0609_063_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	063	0	1	02	01	H0609_063_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	063	0	1	02	01	H0609_063_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	063	0	1	02	01	H0609_063_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	063	0	1	02	01	H0609_063_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	063	0	1	02	01	H0609_063_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	063	0	1	02	01	H0609_063_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				733.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	066	0	1	02	01	H0609_066_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	066	0	1	02	01	H0609_066_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	066	0	1	02	01	H0609_066_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	066	0	1	02	01	H0609_066_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	066	0	1	02	01	H0609_066_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	066	0	1	02	01	H0609_066_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	066	0	1	02	01	H0609_066_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				260.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	067	0	1	02	01	H0609_067_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	067	0	1	02	01	H0609_067_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	067	0	1	02	01	H0609_067_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	067	0	1	02	01	H0609_067_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	067	0	1	02	01	H0609_067_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	067	0	1	02	01	H0609_067_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	067	0	1	02	01	H0609_067_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				279.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	068	0	1	02	01	H0609_068_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	068	0	1	02	01	H0609_068_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	068	0	1	02	01	H0609_068_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	068	0	1	02	01	H0609_068_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	068	0	1	02	01	H0609_068_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	068	0	1	02	01	H0609_068_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	068	0	1	02	01	H0609_068_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				316.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	070	0	1	02	01	H0609_070_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	070	0	1	02	01	H0609_070_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	070	0	1	02	01	H0609_070_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	070	0	1	02	01	H0609_070_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	070	0	1	02	01	H0609_070_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	070	0	1	02	01	H0609_070_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	070	0	1	02	01	H0609_070_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				500.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	071	0	1	02	01	H0609_071_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	071	0	1	02	01	H0609_071_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0609	071	0	1	02	01	H0609_071_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0609	071	0	1	02	01	H0609_071_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0609	071	0	1	02	01	H0609_071_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	071	0	1	02	01	H0609_071_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0609	071	0	1	02	01	H0609_071_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				732.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	001	0	1	02	01	H0628_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	001	0	1	02	01	H0628_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0628	001	0	1	02	01	H0628_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	001	0	1	02	01	H0628_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0628	001	0	1	02	01	H0628_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	001	0	1	02	01	H0628_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	001	0	1	02	01	H0628_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											840.57	33						653.50	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	003	0	1	02	01	H0628_003_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	003	0	1	02	01	H0628_003_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	003	0	1	02	01	H0628_003_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	003	0	1	02	01	H0628_003_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	003	0	1	02	01	H0628_003_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	003	0	1	02	01	H0628_003_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	003	0	1	02	01	H0628_003_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											905.25	33						671.53	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	005	0	1	02	01	H0628_005_0	8			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	005	0	1	02	01	H0628_005_0	8			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	005	0	1	02	01	H0628_005_0	8			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	005	0	1	02	01	H0628_005_0	8			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	005	0	1	02	01	H0628_005_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	005	0	1	02	01	H0628_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	005	0	1	02	01	H0628_005_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											971.56	33						614.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	006	0	1	02	01	H0628_006_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	006	0	1	02	01	H0628_006_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	006	0	1	02	01	H0628_006_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	006	0	1	02	01	H0628_006_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	006	0	1	02	01	H0628_006_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	006	0	1	02	01	H0628_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	006	0	1	02	01	H0628_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.01	33						680.33	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	007	0	1	02	01	H0628_007_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	007	0	1	02	01	H0628_007_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	007	0	1	02	01	H0628_007_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	007	0	1	02	01	H0628_007_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	007	0	1	02	01	H0628_007_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	007	0	1	02	01	H0628_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	007	0	1	02	01	H0628_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											916.82	33						705.67	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	008	0	1	02	01	H0628_008_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	008	0	1	02	01	H0628_008_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	008	0	1	02	01	H0628_008_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	008	0	1	02	01	H0628_008_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	008	0	1	02	01	H0628_008_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	008	0	1	02	01	H0628_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	008	0	1	02	01	H0628_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											872.12	33						688.95	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	009	0	1	02	01	H0628_009_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	009	0	1	02	01	H0628_009_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	009	0	1	02	01	H0628_009_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	009	0	1	02	01	H0628_009_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	009	0	1	02	01	H0628_009_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	009	0	1	02	01	H0628_009_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	009	0	1	02	01	H0628_009_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											891.54	33						663.55	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	010	0	1	02	01	H0628_010_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	010	0	1	02	01	H0628_010_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	010	0	1	02	01	H0628_010_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	010	0	1	02	01	H0628_010_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	010	0	1	02	01	H0628_010_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	010	0	1	02	01	H0628_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	010	0	1	02	01	H0628_010_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											874.40	33						684.05	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	011	0	1	01	01	H0628_011_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	011	0	1	01	01	H0628_011_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	011	0	1	01	01	H0628_011_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	011	0	1	01	01	H0628_011_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	011	0	1	01	01	H0628_011_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	011	0	1	01	01	H0628_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	011	0	1	01	01	H0628_011_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											850.79	33						715.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0628	017	0	1	02	01	H0628_017_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	017	0	1	02	01	H0628_017_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	017	0	1	02	01	H0628_017_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0628	017	0	1	02	01	H0628_017_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0628	017	0	1	02	01	H0628_017_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	017	0	1	02	01	H0628_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0628	017	0	1	02	01	H0628_017_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											909.16	33						611.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0630	013	0	1	01	01	H0630_013_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	013	0	1	01	01	H0630_013_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.66	0.00	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H0630	013	0	1	01	01	H0630_013_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	013	0	1	01	01	H0630_013_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	013	0	1	01	01	H0630_013_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	013	0	1	01	01	H0630_013_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	015	0	1	02	01	H0630_015_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	015	0	1	02	01	H0630_015_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.66	0.00	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H0630	015	0	1	02	01	H0630_015_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	100.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
H0630	015	0	1	02	01	H0630_015_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	015	0	1	02	01	H0630_015_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	015	0	1	02	01	H0630_015_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	016	0	1	02	01	H0630_016_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	016	0	1	02	01	H0630_016_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.66	0.00	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H0630	016	0	1	02	01	H0630_016_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	100.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
H0630	016	0	1	02	01	H0630_016_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	016	0	1	02	01	H0630_016_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	016	0	1	02	01	H0630_016_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	017	0	1	01	01	H0630_017_0	12			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	017	0	1	01	01	H0630_017_0	12			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.66	0.16	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H0630	017	0	1	01	01	H0630_017_0	12			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	017	0	1	01	01	H0630_017_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	017	0	1	01	01	H0630_017_0	12			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	017	0	1	01	01	H0630_017_0	12			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	020	0	1	01	01	H0630_020_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	020	0	1	01	01	H0630_020_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.66	0.00	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H0630	020	0	1	01	01	H0630_020_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	020	0	1	01	01	H0630_020_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	020	0	1	01	01	H0630_020_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	020	0	1	01	01	H0630_020_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	021	0	1	02	01	H0630_021_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	021	0	1	02	01	H0630_021_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.66	0.00	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H0630	021	0	1	02	01	H0630_021_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	100.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
H0630	021	0	1	02	01	H0630_021_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	021	0	1	02	01	H0630_021_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	021	0	1	02	01	H0630_021_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	023	0	1	02	01	H0630_023_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	023	0	1	02	01	H0630_023_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.66	0.16	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H0630	023	0	1	02	01	H0630_023_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	100.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
H0630	023	0	1	02	01	H0630_023_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	023	0	1	02	01	H0630_023_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	023	0	1	02	01	H0630_023_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	025	0	1	02	01	H0630_025_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	025	0	1	02	01	H0630_025_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.66	0.16	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H0630	025	0	1	02	01	H0630_025_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	025	0	1	02	01	H0630_025_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	025	0	1	02	01	H0630_025_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	025	0	1	02	01	H0630_025_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0630	026	0	1	02	01	H0630_026_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H0630	026	0	1	02	01	H0630_026_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.66	0.16	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H0630	026	0	1	02	01	H0630_026_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	026	0	1	02	01	H0630_026_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	240.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	026	0	1	02	01	H0630_026_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H0630	026	0	1	02	01	H0630_026_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H0672	001	0	1	01	01	H0672_001_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0672	001	0	1	01	01	H0672_001_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0672	001	0	1	01	01	H0672_001_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0672	001	0	1	01	01	H0672_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	001	0	1	01	01	H0672_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	001	0	1	01	01	H0672_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											655.50	33						549.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	003	0	1	01	01	H0672_003_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0672	003	0	1	01	01	H0672_003_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0672	003	0	1	01	01	H0672_003_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0672	003	0	1	01	01	H0672_003_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	003	0	1	01	01	H0672_003_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	003	0	1	01	01	H0672_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											818.89	33						709.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	004	0	1	01	01	H0672_004_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0672	004	0	1	01	01	H0672_004_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0672	004	0	1	01	01	H0672_004_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0672	004	0	1	01	01	H0672_004_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	004	0	1	01	01	H0672_004_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	004	0	1	01	01	H0672_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											730.84	33						559.77	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	005	0	1	01	01	H0672_005_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	005	0	1	01	01	H0672_005_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0672	005	0	1	01	01	H0672_005_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H0672	005	0	1	01	01	H0672_005_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	005	0	1	01	01	H0672_005_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	005	0	1	01	01	H0672_005_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											798.35	33						658.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	006	0	1	01	01	H0672_006_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	006	0	1	01	01	H0672_006_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0672	006	0	1	01	01	H0672_006_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H0672	006	0	1	01	01	H0672_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	006	0	1	01	01	H0672_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	006	0	1	01	01	H0672_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											622.82	33						502.69	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	007	0	1	01	01	H0672_007_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0672	007	0	1	01	01	H0672_007_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0672	007	0	1	01	01	H0672_007_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0672	007	0	1	01	01	H0672_007_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	007	0	1	01	01	H0672_007_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	007	0	1	01	01	H0672_007_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.04	33						498.79	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	008	0	1	01	01	H0672_008_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H0672	008	0	1	01	01	H0672_008_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0672	008	0	1	01	01	H0672_008_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H0672	008	0	1	01	01	H0672_008_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	008	0	1	01	01	H0672_008_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	008	0	1	01	01	H0672_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											690.94	33						597.54	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	011	0	1	01	01	H0672_011_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	011	0	1	01	01	H0672_011_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0672	011	0	1	01	01	H0672_011_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H0672	011	0	1	01	01	H0672_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	011	0	1	01	01	H0672_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	011	0	1	01	01	H0672_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											743.06	33						517.05	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	013	0	1	01	01	H0672_013_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	013	0	1	01	01	H0672_013_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0672	013	0	1	01	01	H0672_013_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H0672	013	0	1	01	01	H0672_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	013	0	1	01	01	H0672_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	013	0	1	01	01	H0672_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.16	33						514.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	014	0	1	01	01	H0672_014_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	014	0	1	01	01	H0672_014_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0672	014	0	1	01	01	H0672_014_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H0672	014	0	1	01	01	H0672_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	014	0	1	01	01	H0672_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	014	0	1	01	01	H0672_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.04	33						510.53	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	016	0	1	01	01	H0672_016_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	016	0	1	01	01	H0672_016_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0672	016	0	1	01	01	H0672_016_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H0672	016	0	1	01	01	H0672_016_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	016	0	1	01	01	H0672_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	016	0	1	01	01	H0672_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											746.86	33						514.73	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0672	017	0	1	01	01	H0672_017_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H0672	017	0	1	01	01	H0672_017_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H0672	017	0	1	01	01	H0672_017_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H0672	017	0	1	01	01	H0672_017_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	017	0	1	01	01	H0672_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0672	017	0	1	01	01	H0672_017_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											746.90	33						514.64	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H0710	008	0	1	04	01	H0710_008_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	008	0	1	04	01	H0710_008_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	008	0	1	04	01	H0710_008_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	008	0	1	04	01	H0710_008_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	008	0	1	04	01	H0710_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	008	0	1	04	01	H0710_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				598.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	009	0	1	04	01	H0710_009_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	009	0	1	04	01	H0710_009_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	009	0	1	04	01	H0710_009_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	009	0	1	04	01	H0710_009_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	009	0	1	04	01	H0710_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	009	0	1	04	01	H0710_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				448.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	012	0	1	04	01	H0710_012_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	012	0	1	04	01	H0710_012_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	012	0	1	04	01	H0710_012_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	012	0	1	04	01	H0710_012_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	012	0	1	04	01	H0710_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	012	0	1	04	01	H0710_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				424.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	030	0	1	04	01	H0710_030_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	030	0	1	04	01	H0710_030_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	030	0	1	04	01	H0710_030_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	030	0	1	04	01	H0710_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	030	0	1	04	01	H0710_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	030	0	1	04	01	H0710_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				593.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	037	0	1	04	01	H0710_037_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	037	0	1	04	01	H0710_037_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	037	0	1	04	01	H0710_037_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	037	0	1	04	01	H0710_037_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	037	0	1	04	01	H0710_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	037	0	1	04	01	H0710_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				575.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	047	0	1	04	01	H0710_047_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	047	0	1	04	01	H0710_047_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	047	0	1	04	01	H0710_047_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	047	0	1	04	01	H0710_047_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	047	0	1	04	01	H0710_047_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	047	0	1	04	01	H0710_047_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				462.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	050	0	1	04	01	H0710_050_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	050	0	1	04	01	H0710_050_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	050	0	1	04	01	H0710_050_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	050	0	1	04	01	H0710_050_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	050	0	1	04	01	H0710_050_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	050	0	1	04	01	H0710_050_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	054	0	1	04	01	H0710_054_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	054	0	1	04	01	H0710_054_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	054	0	1	04	01	H0710_054_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	054	0	1	04	01	H0710_054_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	054	0	1	04	01	H0710_054_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	054	0	1	04	01	H0710_054_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	055	0	1	04	01	H0710_055_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	055	0	1	04	01	H0710_055_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	055	0	1	04	01	H0710_055_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	055	0	1	04	01	H0710_055_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	055	0	1	04	01	H0710_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	055	0	1	04	01	H0710_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	056	0	1	04	01	H0710_056_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	056	0	1	04	01	H0710_056_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	056	0	1	04	01	H0710_056_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	056	0	1	04	01	H0710_056_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	056	0	1	04	01	H0710_056_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	056	0	1	04	01	H0710_056_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	057	0	1	04	01	H0710_057_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	057	0	1	04	01	H0710_057_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	057	0	1	04	01	H0710_057_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	057	0	1	04	01	H0710_057_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	057	0	1	04	01	H0710_057_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	057	0	1	04	01	H0710_057_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				485.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	058	0	1	04	01	H0710_058_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	058	0	1	04	01	H0710_058_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	058	0	1	04	01	H0710_058_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	058	0	1	04	01	H0710_058_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	058	0	1	04	01	H0710_058_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	058	0	1	04	01	H0710_058_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				443.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	059	0	1	04	01	H0710_059_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	059	0	1	04	01	H0710_059_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	059	0	1	04	01	H0710_059_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	059	0	1	04	01	H0710_059_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	059	0	1	04	01	H0710_059_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	059	0	1	04	01	H0710_059_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	060	0	1	04	01	H0710_060_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	060	0	1	04	01	H0710_060_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	060	0	1	04	01	H0710_060_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	060	0	1	04	01	H0710_060_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	060	0	1	04	01	H0710_060_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	060	0	1	04	01	H0710_060_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	061	0	1	04	01	H0710_061_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	061	0	1	04	01	H0710_061_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	061	0	1	04	01	H0710_061_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	061	0	1	04	01	H0710_061_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	061	0	1	04	01	H0710_061_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	061	0	1	04	01	H0710_061_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	062	0	1	04	01	H0710_062_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	062	0	1	04	01	H0710_062_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	062	0	1	04	01	H0710_062_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	062	0	1	04	01	H0710_062_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	062	0	1	04	01	H0710_062_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	062	0	1	04	01	H0710_062_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	066	0	1	04	01	H0710_066_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	066	0	1	04	01	H0710_066_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	066	0	1	04	01	H0710_066_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	066	0	1	04	01	H0710_066_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	066	0	1	04	01	H0710_066_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	066	0	1	04	01	H0710_066_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	067	0	1	04	01	H0710_067_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	067	0	1	04	01	H0710_067_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	067	0	1	04	01	H0710_067_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	067	0	1	04	01	H0710_067_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	067	0	1	04	01	H0710_067_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	067	0	1	04	01	H0710_067_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	068	0	1	04	01	H0710_068_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	068	0	1	04	01	H0710_068_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	068	0	1	04	01	H0710_068_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	068	0	1	04	01	H0710_068_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	068	0	1	04	01	H0710_068_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	068	0	1	04	01	H0710_068_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	069	0	1	04	01	H0710_069_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	069	0	1	04	01	H0710_069_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	069	0	1	04	01	H0710_069_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	069	0	1	04	01	H0710_069_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	069	0	1	04	01	H0710_069_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	069	0	1	04	01	H0710_069_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	070	0	1	04	01	H0710_070_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	070	0	1	04	01	H0710_070_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	070	0	1	04	01	H0710_070_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	070	0	1	04	01	H0710_070_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	070	0	1	04	01	H0710_070_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	070	0	1	04	01	H0710_070_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	071	0	1	04	01	H0710_071_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	071	0	1	04	01	H0710_071_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0710	071	0	1	04	01	H0710_071_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0710	071	0	1	04	01	H0710_071_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	071	0	1	04	01	H0710_071_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0710	071	0	1	04	01	H0710_071_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0712	019	0	1	01	01	H0712_019_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	019	0	1	01	01	H0712_019_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	0.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	019	0	1	01	01	H0712_019_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0712	019	0	1	01	01	H0712_019_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.63	48	48	48				99.63	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0712	019	0	1	01	01	H0712_019_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0712	019	0	1	01	01	H0712_019_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	019	0	1	01	01	H0712_019_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0712	020	0	1	01	01	H0712_020_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	020	0	1	01	01	H0712_020_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	020	0	1	01	01	H0712_020_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0712	020	0	1	01	01	H0712_020_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.20	45	45	45				99.20	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0712	020	0	1	01	01	H0712_020_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0712	020	0	1	01	01	H0712_020_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	023	0	1	01	01	H0712_023_0	9			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	023	0	1	01	01	H0712_023_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0712	023	0	1	01	01	H0712_023_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0712	023	0	1	01	01	H0712_023_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.65	50	50	50				92.65	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0712	023	0	1	01	01	H0712_023_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0712	023	0	1	01	01	H0712_023_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0755	030	0	1	02	01	H0755_030_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	030	0	1	02	01	H0755_030_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0755	030	0	1	02	01	H0755_030_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	030	0	1	02	01	H0755_030_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0755	030	0	1	02	01	H0755_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	030	0	1	02	01	H0755_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	030	0	1	02	01	H0755_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				378.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	031	0	1	02	01	H0755_031_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	031	0	1	02	01	H0755_031_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0755	031	0	1	02	01	H0755_031_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	031	0	1	02	01	H0755_031_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0755	031	0	1	02	01	H0755_031_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	031	0	1	02	01	H0755_031_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	031	0	1	02	01	H0755_031_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	033	0	1	02	01	H0755_033_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	033	0	1	02	01	H0755_033_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0755	033	0	1	02	01	H0755_033_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	033	0	1	02	01	H0755_033_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0755	033	0	1	02	01	H0755_033_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	033	0	1	02	01	H0755_033_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	033	0	1	02	01	H0755_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				406.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	038	0	1	02	01	H0755_038_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	038	0	1	02	01	H0755_038_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0755	038	0	1	02	01	H0755_038_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	038	0	1	02	01	H0755_038_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0755	038	0	1	02	01	H0755_038_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	038	0	1	02	01	H0755_038_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	038	0	1	02	01	H0755_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				528.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	044	0	1	02	01	H0755_044_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	044	0	1	02	01	H0755_044_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0755	044	0	1	02	01	H0755_044_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	044	0	1	02	01	H0755_044_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0755	044	0	1	02	01	H0755_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	044	0	1	02	01	H0755_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	044	0	1	02	01	H0755_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				595.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	045	0	1	02	01	H0755_045_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	045	0	1	02	01	H0755_045_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0755	045	0	1	02	01	H0755_045_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0755	045	0	1	02	01	H0755_045_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H0755	045	0	1	02	01	H0755_045_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	045	0	1	02	01	H0755_045_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H0755	045	0	1	02	01	H0755_045_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				691.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H0783	002	0	1	01	01	H0783_002_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									15.00		45.00				0.00		0.00				0.00				0.00		0.00				0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				15.00		45.00	0.00		0.00	0.00		0.00
H0783	002	0	1	01	01	H0783_002_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0783	002	0	1	01	01	H0783_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0783	002	0	1	01	01	H0783_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0783	002	0	1	01	01	H0783_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0783	003	0	1	01	01	H0783_003_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0783	003	0	1	01	01	H0783_003_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0783	003	0	1	01	01	H0783_003_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0783	003	0	1	01	01	H0783_003_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0783	003	0	1	01	01	H0783_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0783	003	0	1	01	01	H0783_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0783	003	0	1	01	01	H0783_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0783	004	0	1	01	01	H0783_004_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H0783	004	0	1	01	01	H0783_004_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0783	004	0	1	01	01	H0783_004_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H0783	004	0	1	01	01	H0783_004_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H0783	004	0	1	01	01	H0783_004_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H0783	004	0	1	01	01	H0783_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H0783	004	0	1	01	01	H0783_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H0838	024	0	1	01	01	H0838_024_0	8		N	Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	024	0	1	01	01	H0838_024_0	8		N	Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	024	0	1	01	01	H0838_024_0	8		N	Generic	4	11	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				5.24	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	024	0	1	01	01	H0838_024_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				84.61	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	024	0	1	01	01	H0838_024_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				36.37	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	024	0	1	01	01	H0838_024_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				111.29	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	024	0	1	01	01	H0838_024_0	8		N	Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	024	0	1	01	01	H0838_024_0	8		N	Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	039	1	1	01	01	H0838_039_1	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	1	1	01	01	H0838_039_1	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	039	1	1	01	01	H0838_039_1	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	9.00	18.00	18.00																					18.00																9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	1	1	01	01	H0838_039_1	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H0838	039	1	1	01	01	H0838_039_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	90.00	180.00	180.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	1	1	01	01	H0838_039_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				74.17	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	1	1	01	01	H0838_039_1	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	1	1	01	01	H0838_039_1	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	039	2	1	01	01	H0838_039_2	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	2	1	01	01	H0838_039_2	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	039	2	1	01	01	H0838_039_2	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	9.00	18.00	18.00																					18.00																9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	2	1	01	01	H0838_039_2	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H0838	039	2	1	01	01	H0838_039_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	90.00	180.00	180.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	2	1	01	01	H0838_039_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				74.17	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	2	1	01	01	H0838_039_2	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	039	2	1	01	01	H0838_039_2	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	040	1	1	01	01	H0838_040_1	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	1	1	01	01	H0838_040_1	9			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	040	1	1	01	01	H0838_040_1	9			Generic	4	11	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				4.96	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	1	1	01	01	H0838_040_1	9			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				103.56	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	040	1	1	01	01	H0838_040_1	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				31.57	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	1	1	01	01	H0838_040_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				76.93	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	1	1	01	01	H0838_040_1	9			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	1	1	01	01	H0838_040_1	9			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	040	2	1	01	01	H0838_040_2	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	2	1	01	01	H0838_040_2	10			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	040	2	1	01	01	H0838_040_2	10			Generic	4	11	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				4.96	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	2	1	01	01	H0838_040_2	10			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				103.56	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	040	2	1	01	01	H0838_040_2	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				31.57	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	2	1	01	01	H0838_040_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				76.93	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	2	1	01	01	H0838_040_2	10			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	040	2	1	01	01	H0838_040_2	10			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	046	0	1	01	01	H0838_046_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	046	0	1	01	01	H0838_046_0	10			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	046	0	1	01	01	H0838_046_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	046	0	1	01	01	H0838_046_0	10			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	046	0	1	01	01	H0838_046_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	046	0	1	01	01	H0838_046_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				80.50	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	046	0	1	01	01	H0838_046_0	10			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	046	0	1	01	01	H0838_046_0	10			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	047	0	1	01	01	H0838_047_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	047	0	1	01	01	H0838_047_0	10			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	047	0	1	01	01	H0838_047_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	047	0	1	01	01	H0838_047_0	10			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H0838	047	0	1	01	01	H0838_047_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	047	0	1	01	01	H0838_047_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				73.89	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	047	0	1	01	01	H0838_047_0	10			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	047	0	1	01	01	H0838_047_0	10			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	049	0	1	01	01	H0838_049_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	049	0	1	01	01	H0838_049_0	9			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	049	0	1	01	01	H0838_049_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	049	0	1	01	01	H0838_049_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	049	0	1	01	01	H0838_049_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	049	0	1	01	01	H0838_049_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				74.46	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	049	0	1	01	01	H0838_049_0	9			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	049	0	1	01	01	H0838_049_0	9			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	050	1	1	01	01	H0838_050_1	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	1	1	01	01	H0838_050_1	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	050	1	1	01	01	H0838_050_1	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	1	1	01	01	H0838_050_1	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	050	1	1	01	01	H0838_050_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	1	1	01	01	H0838_050_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				86.96	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	1	1	01	01	H0838_050_1	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	1	1	01	01	H0838_050_1	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	050	2	1	01	01	H0838_050_2	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	2	1	01	01	H0838_050_2	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	050	2	1	01	01	H0838_050_2	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	2	1	01	01	H0838_050_2	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	050	2	1	01	01	H0838_050_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	2	1	01	01	H0838_050_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				86.96	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	2	1	01	01	H0838_050_2	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	050	2	1	01	01	H0838_050_2	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	051	1	1	01	01	H0838_051_1	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	1	1	01	01	H0838_051_1	9			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	051	1	1	01	01	H0838_051_1	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	1	1	01	01	H0838_051_1	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	051	1	1	01	01	H0838_051_1	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	1	1	01	01	H0838_051_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				92.01	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	1	1	01	01	H0838_051_1	9			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	1	1	01	01	H0838_051_1	9			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0838	051	2	1	01	01	H0838_051_2	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	2	1	01	01	H0838_051_2	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0838	051	2	1	01	01	H0838_051_2	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	2	1	01	01	H0838_051_2	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H0838	051	2	1	01	01	H0838_051_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	2	1	01	01	H0838_051_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				92.01	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	2	1	01	01	H0838_051_2	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0838	051	2	1	01	01	H0838_051_2	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0876	001	0	1	01	01	H0876_001_0	10		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				2.89	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H0876	001	0	1	01	01	H0876_001_0	10		N	Generic	4	01	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				11.50	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H0876	001	0	1	01	01	H0876_001_0	10		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				117.30	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H0876	001	0	1	01	01	H0876_001_0	10		N	Non-Preferred Brand	4	10	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				74.20	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H0876	001	0	1	01	01	H0876_001_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1032.44	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H0885	001	0	1	04	01	H0885_001_0	7			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	001	0	1	04	01	H0885_001_0	7			Generic	4	01	3	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	001	0	1	04	01	H0885_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	001	0	1	04	01	H0885_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	001	0	1	04	01	H0885_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	001	0	1	04	01	H0885_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	002	0	1	04	01	H0885_002_0	7			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	002	0	1	04	01	H0885_002_0	7			Generic	4	01	3	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	5.00	10.00	15.00																									5.00	10.00	15.00				2.50	5.00	7.50				5.00				5.00		0.17				0.17	0.08	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	002	0	1	04	01	H0885_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	002	0	1	04	01	H0885_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	002	0	1	04	01	H0885_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				752.00	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	002	0	1	04	01	H0885_002_0	7			Select Care Drugs	4	01	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	003	0	1	04	01	H0885_003_0	7			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	003	0	1	04	01	H0885_003_0	7			Generic	4	01	3	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	003	0	1	04	01	H0885_003_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	003	0	1	04	01	H0885_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	003	0	1	04	01	H0885_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				758.00	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	003	0	1	04	01	H0885_003_0	7			Select Care Drugs	4	01	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	004	0	1	04	01	H0885_004_0	7			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	004	0	1	04	01	H0885_004_0	7			Generic	4	01	3	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	004	0	1	04	01	H0885_004_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	004	0	1	04	01	H0885_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	004	0	1	04	01	H0885_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				758.00	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	004	0	1	04	01	H0885_004_0	7			Select Care Drugs	4	01	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	005	0	1	04	01	H0885_005_0	7			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	005	0	1	04	01	H0885_005_0	7			Generic	4	01	3	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	005	0	1	04	01	H0885_005_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	005	0	1	04	01	H0885_005_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	005	0	1	04	01	H0885_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				758.00	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	005	0	1	04	01	H0885_005_0	7			Select Care Drugs	4	01	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	006	0	1	04	01	H0885_006_0	7			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	006	0	1	04	01	H0885_006_0	7			Generic	4	01	3	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	006	0	1	04	01	H0885_006_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	006	0	1	04	01	H0885_006_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0885	006	0	1	04	01	H0885_006_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				758.00	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0885	006	0	1	04	01	H0885_006_0	7			Select Care Drugs	4	01	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	003	0	1	01	01	H0908_003_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	003	0	1	01	01	H0908_003_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0908	003	0	1	01	01	H0908_003_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					9.00	18.00	27.00											14.00	28.00	42.00				9.00	18.00	0.00				14.00				14.00			0.47	0.30		0.47	0.30	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	003	0	1	01	01	H0908_003_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0908	003	0	1	01	01	H0908_003_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											94.68	50	50	50				94.68	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0908	003	0	1	01	01	H0908_003_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0908	003	0	1	01	01	H0908_003_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	003	0	1	01	01	H0908_003_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0908	004	0	1	01	01	H0908_004_0	5			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	004	0	1	01	01	H0908_004_0	5			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	004	0	1	01	01	H0908_004_0	5			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0908	004	0	1	01	01	H0908_004_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.45	45	45	45				99.45	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0908	004	0	1	01	01	H0908_004_0	5			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0908	004	0	1	01	01	H0908_004_0	5			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	005	0	1	01	01	H0908_005_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	005	0	1	01	01	H0908_005_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0908	005	0	1	01	01	H0908_005_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0908	005	0	1	01	01	H0908_005_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.96	50	50	50				89.96	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0908	005	0	1	01	01	H0908_005_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0908	005	0	1	01	01	H0908_005_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	002	0	1	02	01	H0913_002_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	002	0	1	02	01	H0913_002_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	002	0	1	02	01	H0913_002_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0913	002	0	1	02	01	H0913_002_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.87	42	42	42				97.87	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0913	002	0	1	02	01	H0913_002_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0913	002	0	1	02	01	H0913_002_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	013	0	1	01	01	H0913_013_0	6		N	Preferred Generic	3	11	1	2	1	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	013	0	1	01	01	H0913_013_0	6		N	Generic	3	11	1	2	2	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	20.00	40.00	60.00																									20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	013	0	1	01	01	H0913_013_0	6		N	Preferred Brand	3	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0913	013	0	1	01	01	H0913_013_0	6		N	Non-Preferred Drug	3	11	1	1	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31				97.95	41	41	41																								41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0913	013	0	1	01	01	H0913_013_0	6		N	Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H0913	013	0	1	01	01	H0913_013_0	6		N	Select Care Drugs	3	11	1	2	6	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	015	0	1	01	01	H0913_015_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	015	0	1	01	01	H0913_015_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	015	0	1	01	01	H0913_015_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0913	015	0	1	01	01	H0913_015_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.23	47	47	47				99.23	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0913	015	0	1	01	01	H0913_015_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0913	015	0	1	01	01	H0913_015_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	017	0	1	01	01	H0913_017_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	017	0	1	01	01	H0913_017_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	017	0	1	01	01	H0913_017_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0913	017	0	1	01	01	H0913_017_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.80	41	41	41				98.80	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0913	017	0	1	01	01	H0913_017_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0913	017	0	1	01	01	H0913_017_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	021	0	1	01	01	H0913_021_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	021	0	1	01	01	H0913_021_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0913	021	0	1	01	01	H0913_021_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0913	021	0	1	01	01	H0913_021_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											79.52	50	50	50				79.52	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0913	021	0	1	01	01	H0913_021_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0913	021	0	1	01	01	H0913_021_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0927	001	0	1	48	05	H0927_001_0	3			Generic Drugs	4	11		2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0927	001	0	1	48	05	H0927_001_0	3			Brand Drugs	4	11		2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0927	001	0	1	48	05	H0927_001_0	3			Non-Medicare OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H0969	001	0	1	04	01	H0969_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	001	0	1	04	01	H0969_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	001	0	1	04	01	H0969_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H0969	001	0	1	04	01	H0969_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.25	46	46	46				99.25	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0969	001	0	1	04	01	H0969_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0969	001	0	1	04	01	H0969_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	003	0	1	04	01	H0969_003_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	003	0	1	04	01	H0969_003_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	003	0	1	04	01	H0969_003_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H0969	003	0	1	04	01	H0969_003_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.88	50	50	50				92.88	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0969	003	0	1	04	01	H0969_003_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0969	003	0	1	04	01	H0969_003_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	003	0	1	04	01	H0969_003_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H0969	005	0	1	04	01	H0969_005_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	005	0	1	04	01	H0969_005_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0969	005	0	1	04	01	H0969_005_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H0969	005	0	1	04	01	H0969_005_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.30	48	48	48				99.30	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H0969	005	0	1	04	01	H0969_005_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H0969	005	0	1	04	01	H0969_005_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	001	0	1	01	01	H0978_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	001	0	1	01	01	H0978_001_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0978	001	0	1	01	01	H0978_001_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	001	0	1	01	01	H0978_001_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	001	0	1	01	01	H0978_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	001	0	1	01	01	H0978_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	001	0	1	01	01	H0978_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	001	0	1	01	01	H0978_001_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	002	0	1	01	01	H0978_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	002	0	1	01	01	H0978_002_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	002	0	1	01	01	H0978_002_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	002	0	1	01	01	H0978_002_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	002	0	1	01	01	H0978_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H0978	002	0	1	01	01	H0978_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	002	0	1	01	01	H0978_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	002	0	1	01	01	H0978_002_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	003	0	1	01	01	H0978_003_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	003	0	1	01	01	H0978_003_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	003	0	1	01	01	H0978_003_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	003	0	1	01	01	H0978_003_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	003	0	1	01	01	H0978_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	003	0	1	01	01	H0978_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	003	0	1	01	01	H0978_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	003	0	1	01	01	H0978_003_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	004	0	1	01	01	H0978_004_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	004	0	1	01	01	H0978_004_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0978	004	0	1	01	01	H0978_004_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	004	0	1	01	01	H0978_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	004	0	1	01	01	H0978_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	004	0	1	01	01	H0978_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	004	0	1	01	01	H0978_004_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	005	0	1	01	01	H0978_005_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	005	0	1	01	01	H0978_005_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0978	005	0	1	01	01	H0978_005_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	005	0	1	01	01	H0978_005_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	005	0	1	01	01	H0978_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	005	0	1	01	01	H0978_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	005	0	1	01	01	H0978_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	005	0	1	01	01	H0978_005_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	006	0	1	01	01	H0978_006_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	006	0	1	01	01	H0978_006_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	006	0	1	01	01	H0978_006_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	006	0	1	01	01	H0978_006_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	006	0	1	01	01	H0978_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H0978	006	0	1	01	01	H0978_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	006	0	1	01	01	H0978_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	006	0	1	01	01	H0978_006_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	007	0	1	01	01	H0978_007_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	007	0	1	01	01	H0978_007_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	007	0	1	01	01	H0978_007_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	007	0	1	01	01	H0978_007_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	007	0	1	01	01	H0978_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	007	0	1	01	01	H0978_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	007	0	1	01	01	H0978_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	007	0	1	01	01	H0978_007_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	008	0	1	01	01	H0978_008_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	008	0	1	01	01	H0978_008_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0978	008	0	1	01	01	H0978_008_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	008	0	1	01	01	H0978_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	008	0	1	01	01	H0978_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	008	0	1	01	01	H0978_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	008	0	1	01	01	H0978_008_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	009	0	1	01	01	H0978_009_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	009	0	1	01	01	H0978_009_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0978	009	0	1	01	01	H0978_009_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	009	0	1	01	01	H0978_009_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H0978	009	0	1	01	01	H0978_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H0978	009	0	1	01	01	H0978_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	009	0	1	01	01	H0978_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	009	0	1	01	01	H0978_009_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	011	0	1	01	01	H0978_011_0	7			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	011	0	1	01	01	H0978_011_0	7			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H0978	011	0	1	01	01	H0978_011_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	011	0	1	01	01	H0978_011_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	35.00	70.00	85.00																			35.00	70.00	85.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00	50.00	55.00				25.00	50.00	55.00				25.00		25.00
H0978	011	0	1	01	01	H0978_011_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	70.00	140.00	190.00																			70.00	140.00	190.00																70.00				70.00		2.33			2.33			2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	011	0	1	01	01	H0978_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0978	011	0	1	01	01	H0978_011_0	7			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	22.00	33.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H0982	002	0	1	01	01	H0982_002_0	13		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	002	0	1	01	01	H0982_002_0	13		N	Generic	4	01	1	1	2	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	002	0	1	01	01	H0982_002_0	13		N	Preferred Brand	4	10	1	1	3	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00										35.00		35.00
H0982	002	0	1	01	01	H0982_002_0	13		N	Non-Preferred Drug	4	10	1	1	4	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	002	0	1	01	01	H0982_002_0	13		N	Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	002	0	1	01	01	H0982_002_0	13		N	Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	007	0	1	01	01	H0982_007_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	007	0	1	01	01	H0982_007_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	007	0	1	01	01	H0982_007_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	007	0	1	01	01	H0982_007_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	007	0	1	01	01	H0982_007_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	15.00		40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													15.00		40.00										15.00		15.00
H0982	007	0	1	01	01	H0982_007_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	70.00		200.00																																					70.00				70.00		2.33						2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	007	0	1	01	01	H0982_007_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				134.54	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	007	0	1	01	01	H0982_007_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	008	0	1	01	01	H0982_008_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	008	0	1	01	01	H0982_008_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	008	0	1	01	01	H0982_008_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	008	0	1	01	01	H0982_008_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	008	0	1	01	01	H0982_008_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	20.00		50.00																																					20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													20.00		50.00										20.00		20.00
H0982	008	0	1	01	01	H0982_008_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	75.00		225.00																																					75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	008	0	1	01	01	H0982_008_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				137.32	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	008	0	1	01	01	H0982_008_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	009	0	1	01	01	H0982_009_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	009	0	1	01	01	H0982_009_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	009	0	1	01	01	H0982_009_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	009	0	1	01	01	H0982_009_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	009	0	1	01	01	H0982_009_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	15.00		40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													15.00		40.00										15.00		15.00
H0982	009	0	1	01	01	H0982_009_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	75.00		225.00																																					75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	009	0	1	01	01	H0982_009_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				133.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	009	0	1	01	01	H0982_009_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	010	0	1	01	01	H0982_010_0	13		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	010	0	1	01	01	H0982_010_0	13		N	Generic	4	01	1	1	2	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	010	0	1	01	01	H0982_010_0	13		N	Preferred Brand	4	10	1	1	3	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00										35.00		35.00
H0982	010	0	1	01	01	H0982_010_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	010	0	1	01	01	H0982_010_0	13		N	Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	010	0	1	01	01	H0982_010_0	13		N	Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	012	0	1	01	01	H0982_012_0	13		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	012	0	1	01	01	H0982_012_0	13		N	Generic	4	01	1	1	2	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	012	0	1	01	01	H0982_012_0	13		N	Preferred Brand	4	10	1	1	3	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00										35.00		35.00
H0982	012	0	1	01	01	H0982_012_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	012	0	1	01	01	H0982_012_0	13		N	Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	012	0	1	01	01	H0982_012_0	13		N	Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	013	0	1	01	01	H0982_013_0	13		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	013	0	1	01	01	H0982_013_0	13		N	Generic	4	01	1	1	2	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	013	0	1	01	01	H0982_013_0	13		N	Preferred Brand	4	10	1	1	3	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00										35.00		35.00
H0982	013	0	1	01	01	H0982_013_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	000		1	30		90				2	2							30		31					25		25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	013	0	1	01	01	H0982_013_0	13		N	Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	013	0	1	01	01	H0982_013_0	13		N	Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	016	0	1	01	01	H0982_016_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	016	0	1	01	01	H0982_016_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	016	0	1	01	01	H0982_016_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	016	0	1	01	01	H0982_016_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	016	0	1	01	01	H0982_016_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	0.00		0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00		0.00										0.00		0.00
H0982	016	0	1	01	01	H0982_016_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	10.00		25.00																																					10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	016	0	1	01	01	H0982_016_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				115.59	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	016	0	1	01	01	H0982_016_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	017	0	1	01	01	H0982_017_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	017	0	1	01	01	H0982_017_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	017	0	1	01	01	H0982_017_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	017	0	1	01	01	H0982_017_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	017	0	1	01	01	H0982_017_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	15.00		40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													15.00		40.00										15.00		15.00
H0982	017	0	1	01	01	H0982_017_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	70.00		200.00																																					70.00				70.00		2.33						2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	017	0	1	01	01	H0982_017_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				134.54	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	017	0	1	01	01	H0982_017_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	018	0	1	01	01	H0982_018_0	13			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	018	0	1	01	01	H0982_018_0	13			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	018	0	1	01	01	H0982_018_0	13			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	018	0	1	01	01	H0982_018_0	13			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	018	0	1	01	01	H0982_018_0	13			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	20.00		50.00																																					20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													20.00		50.00										20.00		20.00
H0982	018	0	1	01	01	H0982_018_0	13			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	75.00		225.00																																					75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	018	0	1	01	01	H0982_018_0	13			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				137.32	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	018	0	1	01	01	H0982_018_0	13			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	019	0	1	01	01	H0982_019_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	019	0	1	01	01	H0982_019_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	019	0	1	01	01	H0982_019_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	019	0	1	01	01	H0982_019_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	019	0	1	01	01	H0982_019_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	15.00		40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													15.00		40.00										15.00		15.00
H0982	019	0	1	01	01	H0982_019_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	75.00		225.00																																					75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	019	0	1	01	01	H0982_019_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				133.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	019	0	1	01	01	H0982_019_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	020	0	1	01	01	H0982_020_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	020	0	1	01	01	H0982_020_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	020	0	1	01	01	H0982_020_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	020	0	1	01	01	H0982_020_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	020	0	1	01	01	H0982_020_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	15.00		40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													15.00		40.00										15.00		15.00
H0982	020	0	1	01	01	H0982_020_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	75.00		225.00																																					75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	020	0	1	01	01	H0982_020_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				133.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	020	0	1	01	01	H0982_020_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	021	0	1	01	01	H0982_021_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	021	0	1	01	01	H0982_021_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	021	0	1	01	01	H0982_021_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	021	0	1	01	01	H0982_021_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	021	0	1	01	01	H0982_021_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	15.00		40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													15.00		40.00										15.00		15.00
H0982	021	0	1	01	01	H0982_021_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	75.00		225.00																																					75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	021	0	1	01	01	H0982_021_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				133.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	021	0	1	01	01	H0982_021_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	022	0	1	01	01	H0982_022_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	022	0	1	01	01	H0982_022_0	12			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	022	0	1	01	01	H0982_022_0	12			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	022	0	1	01	01	H0982_022_0	12			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H0982	022	0	1	01	01	H0982_022_0	12			Preferred Brand	4	10	1	2	3	1	110		01	000		1	30		90				2	2							30		31	0.00		0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00		0.00										0.00		0.00
H0982	022	0	1	01	01	H0982_022_0	12			Non-Preferred Drug	4	10	1	2	4	1	110		01	000		1	30		90				2	2							30		31	10.00		25.00																																					10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	022	0	1	01	01	H0982_022_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	30														30		31				115.59	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H0982	022	0	1	01	01	H0982_022_0	12			Supplemental Drugs	4	11	2	2	6	1	110		01	100		1	30		90				1	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1016	001	0	1	01	01	H1016_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	001	0	1	01	01	H1016_001_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	001	0	1	01	01	H1016_001_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	001	0	1	01	01	H1016_001_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	001	0	1	01	01	H1016_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								35.00	70.00	87.50					25.00	50.00	62.50					25.00	50.00	62.50																35.00				25.00			1.17	0.83	0.83			0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	87.50	25.00	50.00	62.50	25.00	50.00	62.50				35.00		35.00
H1016	001	0	1	01	01	H1016_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								85.00	170.00	212.50					35.00	70.00	87.50					35.00	70.00	87.50																85.00				35.00			2.83	1.17	1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	001	0	1	01	01	H1016_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	021	0	1	01	01	H1016_021_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	021	0	1	01	01	H1016_021_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	021	0	1	01	01	H1016_021_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	021	0	1	01	01	H1016_021_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	021	0	1	01	01	H1016_021_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								40.00	80.00	100.00					30.00	60.00	75.00					30.00	60.00	75.00																40.00				30.00			1.33	1.00	1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		30.00
H1016	021	0	1	01	01	H1016_021_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					65.00	130.00	162.50					65.00	130.00	162.50																100.00				65.00			3.33	2.17	2.17			2.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	021	0	1	01	01	H1016_021_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	023	0	1	01	01	H1016_023_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	023	0	1	01	01	H1016_023_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	023	0	1	01	01	H1016_023_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	023	0	1	01	01	H1016_023_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	023	0	1	01	01	H1016_023_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								25.00	50.00	62.50					0.00	0.00	0.00					0.00	0.00	0.00																25.00				0.00			0.83	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00	50.00	62.50	0.00	0.00	0.00	0.00	0.00	0.00				25.00		0.00
H1016	023	0	1	01	01	H1016_023_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								85.00	170.00	212.50					35.00	70.00	87.50					35.00	70.00	87.50																85.00				35.00			2.83	1.17	1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	023	0	1	01	01	H1016_023_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	024	0	1	01	01	H1016_024_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	024	0	1	01	01	H1016_024_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	024	0	1	01	01	H1016_024_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	024	0	1	01	01	H1016_024_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	024	0	1	01	01	H1016_024_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								30.00	60.00	75.00					10.00	20.00	25.00					10.00	20.00	25.00																30.00				10.00			1.00	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	75.00	10.00	20.00	25.00	10.00	20.00	25.00				30.00		30.00
H1016	024	0	1	01	01	H1016_024_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					65.00	130.00	162.50					65.00	130.00	162.50																100.00				65.00			3.33	2.17	2.17			2.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	024	0	1	01	01	H1016_024_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	025	0	1	02	01	H1016_025_0	9			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	025	0	1	02	01	H1016_025_0	9			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	025	0	1	02	01	H1016_025_0	9			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	025	0	1	02	01	H1016_025_0	9			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	025	0	1	02	01	H1016_025_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								40.00	80.00	100.00					30.00	60.00	75.00					30.00	60.00	75.00																40.00				30.00			1.33	1.00	1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		35.00
H1016	025	0	1	02	01	H1016_025_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					75.00	150.00	187.50					75.00	150.00	187.50																100.00				75.00			3.33	2.50	2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	025	0	1	02	01	H1016_025_0	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	026	0	1	02	01	H1016_026_0	9			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	026	0	1	02	01	H1016_026_0	9			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	026	0	1	02	01	H1016_026_0	9			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	026	0	1	02	01	H1016_026_0	9			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	026	0	1	02	01	H1016_026_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								40.00	80.00	100.00					30.00	60.00	75.00					30.00	60.00	75.00																40.00				30.00			1.33	1.00	1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		35.00
H1016	026	0	1	02	01	H1016_026_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					75.00	150.00	187.50					75.00	150.00	187.50																100.00				75.00			3.33	2.50	2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	026	0	1	02	01	H1016_026_0	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	029	0	1	01	01	H1016_029_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	029	0	1	01	01	H1016_029_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	029	0	1	01	01	H1016_029_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	029	0	1	01	01	H1016_029_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	029	0	1	01	01	H1016_029_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								40.00	80.00	100.00					30.00	60.00	75.00					30.00	60.00	75.00																40.00				30.00			1.33	1.00	1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		35.00
H1016	029	0	1	01	01	H1016_029_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					75.00	150.00	187.50					75.00	150.00	187.50																100.00				75.00			3.33	2.50	2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	029	0	1	01	01	H1016_029_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	030	0	1	01	01	H1016_030_0	7			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	030	0	1	01	01	H1016_030_0	7			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	030	0	1	01	01	H1016_030_0	7			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	50.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				0.00			0.67	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	030	0	1	01	01	H1016_030_0	7			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	50.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				0.00			0.67	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	030	0	1	01	01	H1016_030_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					30.00	60.00	75.00					30.00	60.00	75.00																47.00				30.00			1.57	1.00	1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	87.50	30.00	60.00	75.00	30.00	60.00	75.00				35.00		35.00
H1016	030	0	1	01	01	H1016_030_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					85.00	170.00	212.50					85.00	170.00	212.50																100.00				85.00			3.33	2.83	2.83			2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	030	0	1	01	01	H1016_030_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	031	0	1	01	01	H1016_031_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	031	0	1	01	01	H1016_031_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	031	0	1	01	01	H1016_031_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	031	0	1	01	01	H1016_031_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	031	0	1	01	01	H1016_031_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								25.00	50.00	62.50					0.00	0.00	0.00					0.00	0.00	0.00																25.00				0.00			0.83	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00	50.00	62.50	0.00	0.00	0.00	0.00	0.00	0.00				25.00		0.00
H1016	031	0	1	01	01	H1016_031_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								85.00	170.00	212.50					35.00	70.00	87.50					35.00	70.00	87.50																85.00				35.00			2.83	1.17	1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	031	0	1	01	01	H1016_031_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	032	0	1	01	01	H1016_032_0	8			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	032	0	1	01	01	H1016_032_0	8			Preferred Generic	4	11	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	032	0	1	01	01	H1016_032_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	032	0	1	01	01	H1016_032_0	8			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	25.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		1															
H1016	032	0	1	01	01	H1016_032_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								30.00	60.00	75.00					10.00	20.00	25.00					10.00	20.00	25.00																30.00				10.00			1.00	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	75.00	10.00	20.00	25.00	10.00	20.00	25.00				30.00		10.00
H1016	032	0	1	01	01	H1016_032_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					65.00	130.00	162.50					65.00	130.00	162.50																100.00				65.00			3.33	2.17	2.17			2.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1016	032	0	1	01	01	H1016_032_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											696.39	33						696.39	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1019	001	0	1	01	01	H1019_001_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				5.00		15.00	0.00		0.00	0.00		0.00
H1019	001	0	1	01	01	H1019_001_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	001	0	1	01	01	H1019_001_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	001	0	1	01	01	H1019_001_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	001	0	1	01	01	H1019_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									47.00		141.00				0.00		0.00				0.00				0.00		0.00				1.57	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				35.00		105.00	0.00		0.00	0.00		0.00
H1019	001	0	1	01	01	H1019_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	001	0	1	01	01	H1019_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	006	0	1	01	01	H1019_006_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	006	0	1	01	01	H1019_006_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	006	0	1	01	01	H1019_006_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	006	0	1	01	01	H1019_006_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	006	0	1	01	01	H1019_006_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	006	0	1	01	01	H1019_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									36.00		108.00				25.00		65.00				25.00				25.00		0.83				1.20	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				35.00		105.00	25.00		65.00	25.00		25.00
H1019	006	0	1	01	01	H1019_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	043	0	1	01	01	H1019_043_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	043	0	1	01	01	H1019_043_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	043	0	1	01	01	H1019_043_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	043	0	1	01	01	H1019_043_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	043	0	1	01	01	H1019_043_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									47.00		141.00				25.00		65.00				25.00				25.00		0.83				1.57	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				35.00		105.00	25.00		65.00	25.00		25.00
H1019	043	0	1	01	01	H1019_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	043	0	1	01	01	H1019_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	057	0	1	02	01	H1019_057_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	057	0	1	02	01	H1019_057_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	057	0	1	02	01	H1019_057_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	057	0	1	02	01	H1019_057_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	057	0	1	02	01	H1019_057_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									47.00		141.00				25.00		65.00				25.00				25.00		0.83				1.57	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				35.00		105.00	25.00		65.00	25.00		25.00
H1019	057	0	1	02	01	H1019_057_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	057	0	1	02	01	H1019_057_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	065	0	1	01	01	H1019_065_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	065	0	1	01	01	H1019_065_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	065	0	1	01	01	H1019_065_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									12.00		36.00				0.00		0.00				0.00				0.00		0.00				0.40	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				12.00		36.00	0.00		0.00	0.00		0.00
H1019	065	0	1	01	01	H1019_065_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									12.00		36.00				0.00		0.00				0.00				0.00		0.00				0.40	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	065	0	1	01	01	H1019_065_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	065	0	1	01	01	H1019_065_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	065	0	1	01	01	H1019_065_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	069	0	1	01	01	H1019_069_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	069	0	1	01	01	H1019_069_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	069	0	1	01	01	H1019_069_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	069	0	1	01	01	H1019_069_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	069	0	1	01	01	H1019_069_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	069	0	1	01	01	H1019_069_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	069	0	1	01	01	H1019_069_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	076	0	1	01	01	H1019_076_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	076	0	1	01	01	H1019_076_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	076	0	1	01	01	H1019_076_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	076	0	1	01	01	H1019_076_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	076	0	1	01	01	H1019_076_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	076	0	1	01	01	H1019_076_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	076	0	1	01	01	H1019_076_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	094	0	1	01	01	H1019_094_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	094	0	1	01	01	H1019_094_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	094	0	1	01	01	H1019_094_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	094	0	1	01	01	H1019_094_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	094	0	1	01	01	H1019_094_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	094	0	1	01	01	H1019_094_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	094	0	1	01	01	H1019_094_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	098	0	1	01	01	H1019_098_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	098	0	1	01	01	H1019_098_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	098	0	1	01	01	H1019_098_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	098	0	1	01	01	H1019_098_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	098	0	1	01	01	H1019_098_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	098	0	1	01	01	H1019_098_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	80.00		240.00																									100.00		300.00				80.00		230.00				80.00				80.00		2.67				3.33	2.67	2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	098	0	1	01	01	H1019_098_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	102	0	1	01	01	H1019_102_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				5.00		15.00	0.00		0.00	0.00		0.00
H1019	102	0	1	01	01	H1019_102_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	102	0	1	01	01	H1019_102_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	102	0	1	01	01	H1019_102_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	102	0	1	01	01	H1019_102_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									47.00		141.00				15.00		35.00				15.00				15.00		0.50				1.57	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				35.00		105.00	15.00		35.00	15.00		15.00
H1019	102	0	1	01	01	H1019_102_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	102	0	1	01	01	H1019_102_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	103	1	1	01	01	H1019_103_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	103	1	1	01	01	H1019_103_1	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	103	1	1	01	01	H1019_103_1	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	103	1	1	01	01	H1019_103_1	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	103	1	1	01	01	H1019_103_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1019	103	1	1	01	01	H1019_103_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									100.00		300.00				45.00		125.00				45.00				45.00		1.50				3.33	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	103	1	1	01	01	H1019_103_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	103	2	1	01	01	H1019_103_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	103	2	1	01	01	H1019_103_2	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	103	2	1	01	01	H1019_103_2	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	103	2	1	01	01	H1019_103_2	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	103	2	1	01	01	H1019_103_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1019	103	2	1	01	01	H1019_103_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									100.00		300.00				45.00		125.00				45.00				45.00		1.50				3.33	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	103	2	1	01	01	H1019_103_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	104	1	1	01	01	H1019_104_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	104	1	1	01	01	H1019_104_1	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	104	1	1	01	01	H1019_104_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	104	1	1	01	01	H1019_104_1	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	104	1	1	01	01	H1019_104_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	104	1	1	01	01	H1019_104_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	60.00		180.00																									100.00		300.00				60.00		170.00				60.00				60.00		2.00				3.33	2.00	1.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	104	1	1	01	01	H1019_104_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	104	2	1	01	01	H1019_104_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	104	2	1	01	01	H1019_104_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	104	2	1	01	01	H1019_104_2	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	104	2	1	01	01	H1019_104_2	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	104	2	1	01	01	H1019_104_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	104	2	1	01	01	H1019_104_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	60.00		180.00																									100.00		300.00				60.00		170.00				60.00				60.00		2.00				3.33	2.00	1.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	104	2	1	01	01	H1019_104_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	108	0	1	01	01	H1019_108_0	13			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	108	0	1	01	01	H1019_108_0	13			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	108	0	1	01	01	H1019_108_0	13			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	108	0	1	01	01	H1019_108_0	13			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	108	0	1	01	01	H1019_108_0	13			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	108	0	1	01	01	H1019_108_0	13			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	108	0	1	01	01	H1019_108_0	13			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	109	0	1	01	01	H1019_109_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	109	0	1	01	01	H1019_109_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	109	0	1	01	01	H1019_109_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	109	0	1	01	01	H1019_109_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	109	0	1	01	01	H1019_109_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	109	0	1	01	01	H1019_109_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	109	0	1	01	01	H1019_109_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	110	0	1	02	01	H1019_110_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	110	0	1	02	01	H1019_110_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	110	0	1	02	01	H1019_110_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	110	0	1	02	01	H1019_110_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	110	0	1	02	01	H1019_110_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H1019	110	0	1	02	01	H1019_110_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	110	0	1	02	01	H1019_110_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	113	0	1	01	01	H1019_113_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	113	0	1	01	01	H1019_113_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	113	0	1	01	01	H1019_113_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	113	0	1	01	01	H1019_113_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	113	0	1	01	01	H1019_113_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	113	0	1	01	01	H1019_113_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	113	0	1	01	01	H1019_113_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	117	0	1	01	01	H1019_117_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	117	0	1	01	01	H1019_117_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	117	0	1	01	01	H1019_117_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	117	0	1	01	01	H1019_117_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	117	0	1	01	01	H1019_117_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	117	0	1	01	01	H1019_117_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	117	0	1	01	01	H1019_117_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	118	0	1	01	01	H1019_118_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	118	0	1	01	01	H1019_118_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	118	0	1	01	01	H1019_118_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	118	0	1	01	01	H1019_118_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	118	0	1	01	01	H1019_118_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	118	0	1	01	01	H1019_118_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	118	0	1	01	01	H1019_118_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	120	1	1	01	01	H1019_120_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	120	1	1	01	01	H1019_120_1	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	120	1	1	01	01	H1019_120_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	120	1	1	01	01	H1019_120_1	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	120	1	1	01	01	H1019_120_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	120	1	1	01	01	H1019_120_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	120	1	1	01	01	H1019_120_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	120	2	1	01	01	H1019_120_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	120	2	1	01	01	H1019_120_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	120	2	1	01	01	H1019_120_2	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	120	2	1	01	01	H1019_120_2	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	120	2	1	01	01	H1019_120_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1019	120	2	1	01	01	H1019_120_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	120	2	1	01	01	H1019_120_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	121	0	1	01	01	H1019_121_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H1019	121	0	1	01	01	H1019_121_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	121	0	1	01	01	H1019_121_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									6.00		18.00				5.00		0.00				5.00				5.00		0.17				0.20	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				6.00		18.00	5.00		0.00	5.00		5.00
H1019	121	0	1	01	01	H1019_121_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									6.00		18.00				5.00		0.00				5.00				5.00		0.17				0.20	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	121	0	1	01	01	H1019_121_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									26.00		78.00				25.00		65.00				25.00				25.00		0.83				0.87	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				26.00		78.00	25.00		65.00	25.00		25.00
H1019	121	0	1	01	01	H1019_121_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									86.00		258.00				85.00		245.00				85.00				85.00		2.83				2.87	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	121	0	1	01	01	H1019_121_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	122	0	1	01	01	H1019_122_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	122	0	1	01	01	H1019_122_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	122	0	1	01	01	H1019_122_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	122	0	1	01	01	H1019_122_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	122	0	1	01	01	H1019_122_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	122	0	1	01	01	H1019_122_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	70.00		210.00																									100.00		300.00				70.00		200.00				70.00				70.00		2.33				3.33	2.33	2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	122	0	1	01	01	H1019_122_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	123	0	1	01	01	H1019_123_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H1019	123	0	1	01	01	H1019_123_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	123	0	1	01	01	H1019_123_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									6.00		18.00				5.00		0.00				5.00				5.00		0.17				0.20	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				6.00		18.00	5.00		0.00	5.00		5.00
H1019	123	0	1	01	01	H1019_123_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									6.00		18.00				5.00		0.00				5.00				5.00		0.17				0.20	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	123	0	1	01	01	H1019_123_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									26.00		78.00				25.00		65.00				25.00				25.00		0.83				0.87	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				26.00		78.00	25.00		65.00	25.00		25.00
H1019	123	0	1	01	01	H1019_123_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									86.00		258.00				85.00		245.00				85.00				85.00		2.83				2.87	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	123	0	1	01	01	H1019_123_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	124	0	1	01	01	H1019_124_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	124	0	1	01	01	H1019_124_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	124	0	1	01	01	H1019_124_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									12.00		36.00				5.00		0.00				5.00				5.00		0.17				0.40	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				12.00		36.00	5.00		0.00	5.00		5.00
H1019	124	0	1	01	01	H1019_124_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									12.00		36.00				5.00		0.00				5.00				5.00		0.17				0.40	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	124	0	1	01	01	H1019_124_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	124	0	1	01	01	H1019_124_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	124	0	1	01	01	H1019_124_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	125	0	1	01	01	H1019_125_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	125	0	1	01	01	H1019_125_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	125	0	1	01	01	H1019_125_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	125	0	1	01	01	H1019_125_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	125	0	1	01	01	H1019_125_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	125	0	1	01	01	H1019_125_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	70.00		210.00																									100.00		300.00				70.00		200.00				70.00				70.00		2.33				3.33	2.33	2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	125	0	1	01	01	H1019_125_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	130	0	1	01	01	H1019_130_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	130	0	1	01	01	H1019_130_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	130	0	1	01	01	H1019_130_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									12.00		36.00				5.00		0.00				5.00				5.00		0.17				0.40	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				12.00		36.00	5.00		0.00	5.00		5.00
H1019	130	0	1	01	01	H1019_130_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									12.00		36.00				5.00		0.00				5.00				5.00		0.17				0.40	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	130	0	1	01	01	H1019_130_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	130	0	1	01	01	H1019_130_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	130	0	1	01	01	H1019_130_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	134	0	1	01	01	H1019_134_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	134	0	1	01	01	H1019_134_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	134	0	1	01	01	H1019_134_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1019	134	0	1	01	01	H1019_134_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	134	0	1	01	01	H1019_134_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									47.00		141.00				25.00		65.00				25.00				25.00		0.83				1.57	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				35.00		105.00	25.00		65.00	25.00		25.00
H1019	134	0	1	01	01	H1019_134_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	55.00		165.00																									100.00		300.00				55.00		155.00				55.00				55.00		1.83				3.33	1.83	1.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	134	0	1	01	01	H1019_134_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	135	0	1	01	01	H1019_135_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	135	0	1	01	01	H1019_135_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	135	0	1	01	01	H1019_135_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									12.00		36.00				5.00		0.00				5.00				5.00		0.17				0.40	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				12.00		36.00	5.00		0.00	5.00		5.00
H1019	135	0	1	01	01	H1019_135_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									12.00		36.00				5.00		0.00				5.00				5.00		0.17				0.40	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	135	0	1	01	01	H1019_135_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	135	0	1	01	01	H1019_135_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	135	0	1	01	01	H1019_135_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	136	0	1	01	01	H1019_136_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1019	136	0	1	01	01	H1019_136_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	136	0	1	01	01	H1019_136_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	136	0	1	01	01	H1019_136_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	136	0	1	01	01	H1019_136_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	136	0	1	01	01	H1019_136_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	136	0	1	01	01	H1019_136_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	137	0	1	01	01	H1019_137_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	137	0	1	01	01	H1019_137_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	137	0	1	01	01	H1019_137_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	137	0	1	01	01	H1019_137_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	137	0	1	01	01	H1019_137_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	137	0	1	01	01	H1019_137_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	137	0	1	01	01	H1019_137_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	138	0	1	01	01	H1019_138_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	138	0	1	01	01	H1019_138_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	138	0	1	01	01	H1019_138_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	138	0	1	01	01	H1019_138_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	138	0	1	01	01	H1019_138_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	138	0	1	01	01	H1019_138_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	138	0	1	01	01	H1019_138_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	139	0	1	01	01	H1019_139_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	139	0	1	01	01	H1019_139_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	139	0	1	01	01	H1019_139_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	139	0	1	01	01	H1019_139_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	139	0	1	01	01	H1019_139_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	139	0	1	01	01	H1019_139_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	139	0	1	01	01	H1019_139_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	140	0	1	01	01	H1019_140_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	140	0	1	01	01	H1019_140_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	140	0	1	01	01	H1019_140_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	140	0	1	01	01	H1019_140_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	140	0	1	01	01	H1019_140_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	140	0	1	01	01	H1019_140_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	140	0	1	01	01	H1019_140_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	141	0	1	02	01	H1019_141_0	11			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	141	0	1	02	01	H1019_141_0	11			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	141	0	1	02	01	H1019_141_0	11			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	141	0	1	02	01	H1019_141_0	11			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	141	0	1	02	01	H1019_141_0	11			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	141	0	1	02	01	H1019_141_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	141	0	1	02	01	H1019_141_0	11			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	142	0	1	02	01	H1019_142_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1019	142	0	1	02	01	H1019_142_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	142	0	1	02	01	H1019_142_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1019	142	0	1	02	01	H1019_142_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	142	0	1	02	01	H1019_142_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	142	0	1	02	01	H1019_142_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	142	0	1	02	01	H1019_142_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1019	144	0	1	01	01	H1019_144_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									2.00		6.00				0.00		0.00				0.00				0.00		0.00				0.07	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				2.00		6.00	0.00		0.00	0.00		0.00
H1019	144	0	1	01	01	H1019_144_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									2.00		6.00				0.00		0.00				0.00				0.00		0.00				0.07	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1019	144	0	1	01	01	H1019_144_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									16.00		48.00				5.00		0.00				5.00				5.00		0.17				0.53	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				16.00		48.00	5.00		0.00	5.00		5.00
H1019	144	0	1	01	01	H1019_144_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									16.00		48.00				5.00		0.00				5.00				5.00		0.17				0.53	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1019	144	0	1	01	01	H1019_144_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	144	0	1	01	01	H1019_144_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1019	144	0	1	01	01	H1019_144_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1032	189	0	1	01	01	H1032_189_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	189	0	1	01	01	H1032_189_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	189	0	1	01	01	H1032_189_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	189	0	1	01	01	H1032_189_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1032	189	0	1	01	01	H1032_189_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.77	45	45	45				99.77	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	189	0	1	01	01	H1032_189_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	189	0	1	01	01	H1032_189_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	189	0	1	01	01	H1032_189_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	190	0	1	01	01	H1032_190_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	190	0	1	01	01	H1032_190_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	190	0	1	01	01	H1032_190_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	190	0	1	01	01	H1032_190_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	190	0	1	01	01	H1032_190_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.23	49	49	49				99.23	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	190	0	1	01	01	H1032_190_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	190	0	1	01	01	H1032_190_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	190	0	1	01	01	H1032_190_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	191	0	1	01	01	H1032_191_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	191	0	1	01	01	H1032_191_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	191	0	1	01	01	H1032_191_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	191	0	1	01	01	H1032_191_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	191	0	1	01	01	H1032_191_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.80	50	50	50				80.80	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	191	0	1	01	01	H1032_191_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	191	0	1	01	01	H1032_191_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	191	0	1	01	01	H1032_191_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	192	0	1	01	01	H1032_192_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	192	0	1	01	01	H1032_192_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	192	0	1	01	01	H1032_192_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	192	0	1	01	01	H1032_192_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	192	0	1	01	01	H1032_192_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											71.68	50	50	50				71.68	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	192	0	1	01	01	H1032_192_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	192	0	1	01	01	H1032_192_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	192	0	1	01	01	H1032_192_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	193	0	1	01	01	H1032_193_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	193	0	1	01	01	H1032_193_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	193	0	1	01	01	H1032_193_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	193	0	1	01	01	H1032_193_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	193	0	1	01	01	H1032_193_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.73	45	45	45				99.73	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	193	0	1	01	01	H1032_193_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	193	0	1	01	01	H1032_193_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	193	0	1	01	01	H1032_193_0	8			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	194	0	1	01	01	H1032_194_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	194	0	1	01	01	H1032_194_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	194	0	1	01	01	H1032_194_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	194	0	1	01	01	H1032_194_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	194	0	1	01	01	H1032_194_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.40	42	42	42				98.40	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	194	0	1	01	01	H1032_194_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	194	0	1	01	01	H1032_194_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	194	0	1	01	01	H1032_194_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	195	0	1	01	01	H1032_195_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	195	0	1	01	01	H1032_195_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	195	0	1	01	01	H1032_195_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	195	0	1	01	01	H1032_195_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	195	0	1	01	01	H1032_195_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.49	36	36	36				97.49	36	36	36										36	36	36				36	36	36			36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	195	0	1	01	01	H1032_195_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	195	0	1	01	01	H1032_195_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	195	0	1	01	01	H1032_195_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	196	0	1	01	01	H1032_196_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	196	0	1	01	01	H1032_196_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	196	0	1	01	01	H1032_196_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	196	0	1	01	01	H1032_196_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	196	0	1	01	01	H1032_196_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.68	43	43	43				98.68	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	196	0	1	01	01	H1032_196_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	196	0	1	01	01	H1032_196_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	196	0	1	01	01	H1032_196_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	198	0	1	01	01	H1032_198_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	198	0	1	01	01	H1032_198_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	198	0	1	01	01	H1032_198_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	198	0	1	01	01	H1032_198_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	198	0	1	01	01	H1032_198_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.95	42	42	42				99.95	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	198	0	1	01	01	H1032_198_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	198	0	1	01	01	H1032_198_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	198	0	1	01	01	H1032_198_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	199	0	1	01	01	H1032_199_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	199	0	1	01	01	H1032_199_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	199	0	1	01	01	H1032_199_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	199	0	1	01	01	H1032_199_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	199	0	1	01	01	H1032_199_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.16	42	42	42				99.16	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	199	0	1	01	01	H1032_199_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	199	0	1	01	01	H1032_199_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	199	0	1	01	01	H1032_199_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	200	0	1	01	01	H1032_200_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	200	0	1	01	01	H1032_200_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	200	0	1	01	01	H1032_200_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	200	0	1	01	01	H1032_200_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1032	200	0	1	01	01	H1032_200_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.03	49	49	49				98.03	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	200	0	1	01	01	H1032_200_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	200	0	1	01	01	H1032_200_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	200	0	1	01	01	H1032_200_0	8			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	201	0	1	01	01	H1032_201_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	201	0	1	01	01	H1032_201_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	201	0	1	01	01	H1032_201_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	201	0	1	01	01	H1032_201_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	201	0	1	01	01	H1032_201_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.97	50	50	50				97.97	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	201	0	1	01	01	H1032_201_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	201	0	1	01	01	H1032_201_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	201	0	1	01	01	H1032_201_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	204	0	1	01	01	H1032_204_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	204	0	1	01	01	H1032_204_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	204	0	1	01	01	H1032_204_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	204	0	1	01	01	H1032_204_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	204	0	1	01	01	H1032_204_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											70.14	50	50	50				70.14	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	204	0	1	01	01	H1032_204_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	204	0	1	01	01	H1032_204_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	204	0	1	01	01	H1032_204_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	205	0	1	01	01	H1032_205_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	205	0	1	01	01	H1032_205_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	205	0	1	01	01	H1032_205_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	205	0	1	01	01	H1032_205_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	205	0	1	01	01	H1032_205_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											71.08	50	50	50				71.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	205	0	1	01	01	H1032_205_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	205	0	1	01	01	H1032_205_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	205	0	1	01	01	H1032_205_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	209	0	1	01	01	H1032_209_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	209	0	1	01	01	H1032_209_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	209	0	1	01	01	H1032_209_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	209	0	1	01	01	H1032_209_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1032	209	0	1	01	01	H1032_209_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											96.37	50	50	50				96.37	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	209	0	1	01	01	H1032_209_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	209	0	1	01	01	H1032_209_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	209	0	1	01	01	H1032_209_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	210	0	1	01	01	H1032_210_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	210	0	1	01	01	H1032_210_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	210	0	1	01	01	H1032_210_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	210	0	1	01	01	H1032_210_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1032	210	0	1	01	01	H1032_210_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.26	43	43	43				98.26	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	210	0	1	01	01	H1032_210_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	210	0	1	01	01	H1032_210_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	210	0	1	01	01	H1032_210_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	211	0	1	01	01	H1032_211_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	211	0	1	01	01	H1032_211_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	211	0	1	01	01	H1032_211_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	211	0	1	01	01	H1032_211_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	211	0	1	01	01	H1032_211_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.10	46	46	46				98.10	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	211	0	1	01	01	H1032_211_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	211	0	1	01	01	H1032_211_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	211	0	1	01	01	H1032_211_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	212	0	1	01	01	H1032_212_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	212	0	1	01	01	H1032_212_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	212	0	1	01	01	H1032_212_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	212	0	1	01	01	H1032_212_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	212	0	1	01	01	H1032_212_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.00	44	44	44				98.00	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	212	0	1	01	01	H1032_212_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	212	0	1	01	01	H1032_212_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	212	0	1	01	01	H1032_212_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	213	0	1	01	01	H1032_213_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	213	0	1	01	01	H1032_213_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	213	0	1	01	01	H1032_213_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	213	0	1	01	01	H1032_213_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1032	213	0	1	01	01	H1032_213_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.42	43	43	43				98.42	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	213	0	1	01	01	H1032_213_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	213	0	1	01	01	H1032_213_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	213	0	1	01	01	H1032_213_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	218	0	1	01	01	H1032_218_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	218	0	1	01	01	H1032_218_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	218	0	1	01	01	H1032_218_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	218	0	1	01	01	H1032_218_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1032	218	0	1	01	01	H1032_218_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											94.63	50	50	50				94.63	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	218	0	1	01	01	H1032_218_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1032	218	0	1	01	01	H1032_218_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	218	0	1	01	01	H1032_218_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1032	237	0	1	01	01	H1032_237_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	237	0	1	01	01	H1032_237_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1032	237	0	1	01	01	H1032_237_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	237	0	1	01	01	H1032_237_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	30.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	30.00	20.00		20.00
H1032	237	0	1	01	01	H1032_237_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											96.21	50	50	50				96.21	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1032	237	0	1	01	01	H1032_237_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1032	237	0	1	01	01	H1032_237_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1032	237	0	1	01	01	H1032_237_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1035	002	0	1	02	01	H1035_002_0	10			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													17.00	34.00	51.00	0.00	0.00	0.00		0.00	0.00				17.00		17.00
H1035	002	0	1	02	01	H1035_002_0	10			Preferred Generic	4	01	1	2	1	3		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	002	0	1	02	01	H1035_002_0	10			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					0.00	0.00	0.00						0.00	0.00																20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	0.00	0.00	0.00		0.00	0.00				20.00		20.00
H1035	002	0	1	02	01	H1035_002_0	10			Generic	4	01	1	2	2	3		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					0.00	0.00	0.00						0.00	0.00																20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	002	0	1	02	01	H1035_002_0	10			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	2	1		62	93				31		31								47.00	94.00	141.00					42.00	84.00	126.00						82.00	123.00																47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	002	0	1	02	01	H1035_002_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	101		1				31	62	93	2	1		62	93				31		31								100.00	200.00	300.00					92.00	184.00	276.00						182.00	273.00																100.00				100.00			3.23	2.97				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	002	0	1	02	01	H1035_002_0	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1560.80	33						732.93	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00			35.00									35.00		35.00
H1035	002	0	1	02	01	H1035_002_0	10			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01	000		1				31											31		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1035	006	0	1	01	01	H1035_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													17.00	34.00	51.00	0.00	0.00	0.00		0.00	0.00				17.00		17.00
H1035	006	0	1	01	01	H1035_006_0	8			Preferred Generic	4	01	1	2	1	3		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	006	0	1	01	01	H1035_006_0	8			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					6.00	12.00	18.00						10.00	15.00																20.00				20.00			0.65	0.19				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	6.00	12.00	18.00		10.00	15.00				20.00		20.00
H1035	006	0	1	01	01	H1035_006_0	8			Generic	4	01	1	2	2	3		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					6.00	12.00	18.00						10.00	15.00																20.00				20.00			0.65	0.19				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	006	0	1	01	01	H1035_006_0	8			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	2	1		62	93				31		31								47.00	94.00	141.00					44.00	88.00	132.00						86.00	129.00																47.00				47.00			1.52	1.42				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	006	0	1	01	01	H1035_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	101		1				31	62	93	2	1		62	93				31		31								100.00	200.00	300.00					95.00	190.00	285.00						188.00	282.00																100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	006	0	1	01	01	H1035_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1113.35	26						573.49	26																							26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00			35.00									35.00		35.00
H1035	006	0	1	01	01	H1035_006_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01	000		1				31											31		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1035	011	0	1	01	01	H1035_011_0	8			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													17.00	34.00	51.00	0.00	0.00	0.00		0.00	0.00				17.00		17.00
H1035	011	0	1	01	01	H1035_011_0	8			Preferred Generic	4	01	1	2	1	3		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	011	0	1	01	01	H1035_011_0	8			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					7.00	14.00	21.00						12.00	18.00																20.00				20.00			0.65	0.23				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	7.00	14.00	21.00		12.00	18.00				20.00		20.00
H1035	011	0	1	01	01	H1035_011_0	8			Generic	4	01	1	2	2	3		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					7.00	14.00	21.00						12.00	18.00																20.00				20.00			0.65	0.23				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	011	0	1	01	01	H1035_011_0	8			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	2	1		62	93				31		31								47.00	94.00	141.00					45.00	90.00	135.00						88.00	132.00																47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	011	0	1	01	01	H1035_011_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	101		1				31	62	93	2	1		62	93				31		31								100.00	200.00	300.00					98.00	196.00	294.00						194.00	291.00																100.00				100.00			3.23	3.16				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	011	0	1	01	01	H1035_011_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1540.11	33						866.41	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00			35.00									35.00		35.00
H1035	011	0	1	01	01	H1035_011_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01	000		1				31											31		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1035	014	0	1	01	01	H1035_014_0	7			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													17.00	34.00	51.00	0.00	0.00	0.00		0.00	0.00				17.00		17.00
H1035	014	0	1	01	01	H1035_014_0	7			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					10.00	20.00	30.00						18.00	27.00																20.00				20.00			0.65	0.32				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	10.00	20.00	30.00		18.00	27.00				20.00		20.00
H1035	014	0	1	01	01	H1035_014_0	7			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	2	1		62	93				31		31								47.00	94.00	141.00					45.00	90.00	135.00						88.00	132.00																47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	014	0	1	01	01	H1035_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	101		1				31	62	93	2	1		62	93				31		31								100.00	200.00	300.00					98.00	196.00	294.00						194.00	291.00																100.00				100.00			3.23	3.16				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	014	0	1	01	01	H1035_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1482.22	25						617.37	25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00			35.00									35.00		35.00
H1035	014	0	1	01	01	H1035_014_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01	000		1				31											31		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1035	016	0	1	01	01	H1035_016_0	7			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	2	1		62	93				31		31								10.00	20.00	30.00					0.00	0.00	0.00						0.00	0.00																10.00				10.00			0.32	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00		0.00	0.00				10.00		10.00
H1035	016	0	1	01	01	H1035_016_0	7			Preferred Generic	4	01	1	2	1	3		111	01	101		1				31	62	93	2	1		62	93				31		31								10.00	20.00	30.00					0.00	0.00	0.00						0.00	0.00																10.00				10.00			0.32	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	016	0	1	01	01	H1035_016_0	7			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					5.00	10.00	15.00						8.00	12.00																20.00				20.00			0.65	0.16				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00		8.00	12.00				20.00		20.00
H1035	016	0	1	01	01	H1035_016_0	7			Generic	4	01	1	2	2	3		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					5.00	10.00	15.00						8.00	12.00																20.00				20.00			0.65	0.16				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	016	0	1	01	01	H1035_016_0	7			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	2	1		62	93				31		31								47.00	94.00	141.00					44.00	88.00	132.00						86.00	129.00																47.00				47.00			1.52	1.42				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	016	0	1	01	01	H1035_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	101		1				31	62	93	2	1		62	93				31		31								100.00	200.00	300.00					95.00	190.00	285.00						188.00	282.00																100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	016	0	1	01	01	H1035_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1896.99	33						850.46	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00			35.00									35.00		35.00
H1035	016	0	1	01	01	H1035_016_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01	000		1				31											31		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1035	017	0	1	01	01	H1035_017_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	017	0	1	01	01	H1035_017_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	017	0	1	01	01	H1035_017_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	017	0	1	01	01	H1035_017_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	017	0	1	01	01	H1035_017_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	35.00		105.00																			35.00		105.00																35.00				35.00		1.13			1.13			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	017	0	1	01	01	H1035_017_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	017	0	1	01	01	H1035_017_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1130.39	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	018	0	1	01	01	H1035_018_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	018	0	1	01	01	H1035_018_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	018	0	1	01	01	H1035_018_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	018	0	1	01	01	H1035_018_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	018	0	1	01	01	H1035_018_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	35.00		105.00																			35.00		105.00																35.00				35.00		1.13			1.13			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	018	0	1	01	01	H1035_018_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	018	0	1	01	01	H1035_018_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1335.57	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1035	018	0	1	01	01	H1035_018_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	018	0	1	01	01	H1035_018_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	019	0	1	01	01	H1035_019_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	019	0	1	01	01	H1035_019_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	019	0	1	01	01	H1035_019_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	019	0	1	01	01	H1035_019_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	019	0	1	01	01	H1035_019_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	019	0	1	01	01	H1035_019_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1584.19	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1035	019	0	1	01	01	H1035_019_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	019	0	1	01	01	H1035_019_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	020	0	1	01	01	H1035_020_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	020	0	1	01	01	H1035_020_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	020	0	1	01	01	H1035_020_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	020	0	1	01	01	H1035_020_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	020	0	1	01	01	H1035_020_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	020	0	1	01	01	H1035_020_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	020	0	1	01	01	H1035_020_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1806.65	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1035	020	0	1	01	01	H1035_020_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	020	0	1	01	01	H1035_020_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	021	0	1	01	01	H1035_021_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	021	0	1	01	01	H1035_021_0	10			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	021	0	1	01	01	H1035_021_0	10			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	8.00		24.00																			8.00		24.00																8.00				8.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	021	0	1	01	01	H1035_021_0	10			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	8.00		24.00																			8.00		24.00																8.00				8.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	021	0	1	01	01	H1035_021_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	021	0	1	01	01	H1035_021_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	021	0	1	01	01	H1035_021_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1667.26	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1035	021	0	1	01	01	H1035_021_0	10			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	021	0	1	01	01	H1035_021_0	10			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	022	0	1	01	01	H1035_022_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	022	0	1	01	01	H1035_022_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	022	0	1	01	01	H1035_022_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	022	0	1	01	01	H1035_022_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	022	0	1	01	01	H1035_022_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	35.00		105.00																			35.00		105.00																35.00				35.00		1.13			1.13			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	022	0	1	01	01	H1035_022_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	022	0	1	01	01	H1035_022_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1495.82	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	023	0	1	01	01	H1035_023_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	023	0	1	01	01	H1035_023_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	023	0	1	01	01	H1035_023_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	023	0	1	01	01	H1035_023_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	023	0	1	01	01	H1035_023_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	25.00		75.00																			25.00		75.00																25.00				25.00		0.81			0.81			0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		75.00				25.00		25.00
H1035	023	0	1	01	01	H1035_023_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	80.00		240.00																			80.00		240.00																80.00				80.00		2.58			2.58			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	023	0	1	01	01	H1035_023_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1395.97	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	024	0	1	01	01	H1035_024_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	024	0	1	01	01	H1035_024_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	024	0	1	01	01	H1035_024_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	024	0	1	01	01	H1035_024_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	024	0	1	01	01	H1035_024_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1035	024	0	1	01	01	H1035_024_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	50.00		150.00																			50.00		150.00																50.00				50.00		1.61			1.61			1.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	024	0	1	01	01	H1035_024_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1157.04	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	025	0	1	01	01	H1035_025_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	025	0	1	01	01	H1035_025_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	025	0	1	01	01	H1035_025_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	025	0	1	01	01	H1035_025_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	025	0	1	01	01	H1035_025_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	20.00		60.00																			20.00		60.00																20.00				20.00		0.65			0.65			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00				20.00		20.00
H1035	025	0	1	01	01	H1035_025_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	025	0	1	01	01	H1035_025_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1280.12	33																				31																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	026	0	1	01	01	H1035_026_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	026	0	1	01	01	H1035_026_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	026	0	1	01	01	H1035_026_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	026	0	1	01	01	H1035_026_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	026	0	1	01	01	H1035_026_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	30.00		90.00																			30.00		90.00																30.00				30.00		0.97			0.97			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		90.00				30.00		30.00
H1035	026	0	1	01	01	H1035_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	026	0	1	01	01	H1035_026_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1686.98	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	027	0	1	01	01	H1035_027_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.41	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	027	0	1	01	01	H1035_027_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.71	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	027	0	1	01	01	H1035_027_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				80.16	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	027	0	1	01	01	H1035_027_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				109.69	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	027	0	1	01	01	H1035_027_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				805.64	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	028	0	1	01	01	H1035_028_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.34	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	028	0	1	01	01	H1035_028_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.68	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	028	0	1	01	01	H1035_028_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				78.21	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	028	0	1	01	01	H1035_028_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				102.12	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	028	0	1	01	01	H1035_028_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				797.30	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	029	0	1	01	01	H1035_029_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.25	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	029	0	1	01	01	H1035_029_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.24	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	029	0	1	01	01	H1035_029_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				77.26	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	029	0	1	01	01	H1035_029_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				117.87	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	029	0	1	01	01	H1035_029_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				779.48	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	030	0	1	01	01	H1035_030_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.17	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	030	0	1	01	01	H1035_030_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.07	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	030	0	1	01	01	H1035_030_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				71.57	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	030	0	1	01	01	H1035_030_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				104.79	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	030	0	1	01	01	H1035_030_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				788.14	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	031	0	1	01	01	H1035_031_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.26	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	031	0	1	01	01	H1035_031_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.48	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	031	0	1	01	01	H1035_031_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				75.27	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	031	0	1	01	01	H1035_031_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				105.17	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	031	0	1	01	01	H1035_031_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				769.17	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	032	0	1	01	01	H1035_032_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.30	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	032	0	1	01	01	H1035_032_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.40	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	032	0	1	01	01	H1035_032_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				79.02	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	032	0	1	01	01	H1035_032_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				112.80	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	032	0	1	01	01	H1035_032_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				816.86	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	033	0	1	01	01	H1035_033_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	033	0	1	01	01	H1035_033_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	033	0	1	01	01	H1035_033_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	033	0	1	01	01	H1035_033_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	033	0	1	01	01	H1035_033_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	033	0	1	01	01	H1035_033_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	033	0	1	01	01	H1035_033_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				2005.77	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	034	0	1	01	01	H1035_034_0	10			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	034	0	1	01	01	H1035_034_0	10			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	034	0	1	01	01	H1035_034_0	10			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	034	0	1	01	01	H1035_034_0	10			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	034	0	1	01	01	H1035_034_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	30.00		90.00																			30.00		90.00																30.00				30.00		0.97			0.97			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		90.00				30.00		30.00
H1035	034	0	1	01	01	H1035_034_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	90.00		270.00																			90.00		270.00																90.00				90.00		2.90			2.90			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	034	0	1	01	01	H1035_034_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1386.11	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	040	0	1	01	01	H1035_040_0	8			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													17.00	34.00	51.00	0.00	0.00	0.00		0.00	0.00				17.00		17.00
H1035	040	0	1	01	01	H1035_040_0	8			Preferred Generic	4	01	1	2	1	3		111	01	101		1				31	62	93	2	1		62	93				31		31								17.00	34.00	51.00					0.00	0.00	0.00						0.00	0.00																17.00				17.00			0.55	0.00				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	040	0	1	01	01	H1035_040_0	8			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					5.00	10.00	15.00						8.00	12.00																20.00				20.00			0.65	0.16				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00		8.00	12.00				20.00		20.00
H1035	040	0	1	01	01	H1035_040_0	8			Generic	4	01	1	2	2	3		111	01	101		1				31	62	93	2	1		62	93				31		31								20.00	40.00	60.00					5.00	10.00	15.00						8.00	12.00																20.00				20.00			0.65	0.16				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1035	040	0	1	01	01	H1035_040_0	8			Preferred Brand	4	10	1	2	3	1		111	01	101		1				31	62	93	2	1		62	93				31		31								47.00	94.00	141.00					44.00	88.00	132.00						86.00	129.00																47.00				47.00			1.52	1.42				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	040	0	1	01	01	H1035_040_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	101		1				31	62	93	2	1		62	93				31		31								100.00	200.00	300.00					95.00	190.00	285.00						188.00	282.00																100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00				35.00		35.00
H1035	040	0	1	01	01	H1035_040_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											1195.84	33						572.97	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00			35.00									35.00		35.00
H1035	040	0	1	01	01	H1035_040_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01	000		1				31											31		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1035	043	0	1	01	01	H1035_043_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	043	0	1	01	01	H1035_043_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	043	0	1	01	01	H1035_043_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	043	0	1	01	01	H1035_043_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	043	0	1	01	01	H1035_043_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	35.00		105.00																			35.00		105.00																35.00				35.00		1.13			1.13			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	043	0	1	01	01	H1035_043_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	043	0	1	01	01	H1035_043_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1796.92	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	045	0	1	01	01	H1035_045_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	045	0	1	01	01	H1035_045_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	045	0	1	01	01	H1035_045_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	045	0	1	01	01	H1035_045_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	045	0	1	01	01	H1035_045_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	30.00		90.00																			30.00		90.00																30.00				30.00		0.97			0.97			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		90.00				30.00		30.00
H1035	045	0	1	01	01	H1035_045_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	90.00		270.00																			90.00		270.00																90.00				90.00		2.90			2.90			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	045	0	1	01	01	H1035_045_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1277.57	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	046	0	1	01	01	H1035_046_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	046	0	1	01	01	H1035_046_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	046	0	1	01	01	H1035_046_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	5.00		15.00																			5.00		15.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	046	0	1	01	01	H1035_046_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	046	0	1	01	01	H1035_046_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	046	0	1	01	01	H1035_046_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1734.33	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1035	046	0	1	01	01	H1035_046_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	046	0	1	01	01	H1035_046_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	047	0	1	01	01	H1035_047_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	047	0	1	01	01	H1035_047_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	047	0	1	01	01	H1035_047_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	047	0	1	01	01	H1035_047_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	047	0	1	01	01	H1035_047_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H1035	047	0	1	01	01	H1035_047_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1385.16	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1035	047	0	1	01	01	H1035_047_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1035	047	0	1	01	01	H1035_047_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1035	048	0	1	01	01	H1035_048_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	048	0	1	01	01	H1035_048_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	048	0	1	01	01	H1035_048_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	048	0	1	01	01	H1035_048_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	048	0	1	01	01	H1035_048_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	35.00		105.00																			35.00		105.00																35.00				35.00		1.13			1.13			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	048	0	1	01	01	H1035_048_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	048	0	1	01	01	H1035_048_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1314.20	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	050	0	1	01	01	H1035_050_0	12		N	Preferred Generic	4	01	3	1	1	1	110		01	110		1	31		100				1	2	31		100				31		31				0.18	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	050	0	1	01	01	H1035_050_0	12		N	Generic	4	01	1	1	2	1	110		01	110		1	31		100				1	2	31		100				31		31				4.29	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	050	0	1	01	01	H1035_050_0	12		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				78.33	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	050	0	1	01	01	H1035_050_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				109.30	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	050	0	1	01	01	H1035_050_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				792.04	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1035	052	0	1	01	01	H1035_052_0	9			Preferred Generic	4	01	3	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	052	0	1	01	01	H1035_052_0	9			Preferred Generic	4	01	3	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1035	052	0	1	01	01	H1035_052_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1035	052	0	1	01	01	H1035_052_0	9			Generic	4	01	1	2	2	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1035	052	0	1	01	01	H1035_052_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	25.00		75.00																			25.00		75.00																25.00				25.00		0.81			0.81			0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		75.00				25.00		25.00
H1035	052	0	1	01	01	H1035_052_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	80.00		240.00																			80.00		240.00																80.00				80.00		2.58			2.58			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H1035	052	0	1	01	01	H1035_052_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1288.79	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1036	025	0	1	01	01	H1036_025_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	025	0	1	01	01	H1036_025_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	025	0	1	01	01	H1036_025_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	025	0	1	01	01	H1036_025_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1036	025	0	1	01	01	H1036_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	55.00		165.00																									100.00		300.00				55.00		155.00				55.00				55.00		1.83				3.33	1.83	1.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	025	0	1	01	01	H1036_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	044	0	1	01	01	H1036_044_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	044	0	1	01	01	H1036_044_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	044	0	1	01	01	H1036_044_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	044	0	1	01	01	H1036_044_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	044	0	1	01	01	H1036_044_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	044	0	1	01	01	H1036_044_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	044	0	1	01	01	H1036_044_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	054	0	1	01	01	H1036_054_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	054	0	1	01	01	H1036_054_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				5.00		15.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	054	0	1	01	01	H1036_054_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				5.00		15.00	0.00		0.00	0.00		0.00
H1036	054	0	1	01	01	H1036_054_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									50.00		150.00				5.00		5.00				5.00				5.00		0.17				1.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1036	054	0	1	01	01	H1036_054_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	062	0	1	01	01	H1036_062_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	062	0	1	01	01	H1036_062_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	062	0	1	01	01	H1036_062_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	062	0	1	01	01	H1036_062_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	062	0	1	01	01	H1036_062_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									47.00		141.00				15.00		35.00				15.00				15.00		0.50				1.57	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				35.00		105.00	15.00		35.00	15.00		15.00
H1036	062	0	1	01	01	H1036_062_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	062	0	1	01	01	H1036_062_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	065	0	1	01	01	H1036_065_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				5.00		15.00	0.00		0.00	0.00		0.00
H1036	065	0	1	01	01	H1036_065_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	065	0	1	01	01	H1036_065_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	065	0	1	01	01	H1036_065_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	065	0	1	01	01	H1036_065_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1036	065	0	1	01	01	H1036_065_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	065	0	1	01	01	H1036_065_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	068	0	1	01	01	H1036_068_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	068	0	1	01	01	H1036_068_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	068	0	1	01	01	H1036_068_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	068	0	1	01	01	H1036_068_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	068	0	1	01	01	H1036_068_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H1036	068	0	1	01	01	H1036_068_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	75.00		225.00																									100.00		300.00				75.00		215.00				75.00				75.00		2.50				3.33	2.50	2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	068	0	1	01	01	H1036_068_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	074	0	1	01	01	H1036_074_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	074	0	1	01	01	H1036_074_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	074	0	1	01	01	H1036_074_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	074	0	1	01	01	H1036_074_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	074	0	1	01	01	H1036_074_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									47.00		141.00				10.00		20.00				10.00				10.00		0.33				1.57	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				35.00		105.00	10.00		20.00	10.00		10.00
H1036	074	0	1	01	01	H1036_074_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	60.00		180.00																									100.00		300.00				60.00		170.00				60.00				60.00		2.00				3.33	2.00	1.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	074	0	1	01	01	H1036_074_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	121	0	1	01	01	H1036_121_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	121	0	1	01	01	H1036_121_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	121	0	1	01	01	H1036_121_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	121	0	1	01	01	H1036_121_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	121	0	1	01	01	H1036_121_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	40.00		120.00																									45.00		135.00				40.00		110.00				40.00				40.00		1.33				1.50	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	121	0	1	01	01	H1036_121_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									90.00		270.00				85.00		245.00				85.00				85.00		2.83				3.00	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	121	0	1	01	01	H1036_121_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	137	0	1	02	01	H1036_137_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	137	0	1	02	01	H1036_137_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	137	0	1	02	01	H1036_137_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	137	0	1	02	01	H1036_137_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	137	0	1	02	01	H1036_137_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	143	0	1	01	01	H1036_143_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	143	0	1	01	01	H1036_143_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	143	0	1	01	01	H1036_143_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	143	0	1	01	01	H1036_143_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	143	0	1	01	01	H1036_143_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	143	0	1	01	01	H1036_143_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	143	0	1	01	01	H1036_143_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	146	0	1	01	01	H1036_146_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	146	0	1	01	01	H1036_146_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	146	0	1	01	01	H1036_146_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	146	0	1	01	01	H1036_146_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	146	0	1	01	01	H1036_146_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H1036	146	0	1	01	01	H1036_146_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	146	0	1	01	01	H1036_146_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	151	0	1	01	01	H1036_151_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	151	0	1	01	01	H1036_151_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	151	0	1	01	01	H1036_151_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	151	0	1	01	01	H1036_151_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	151	0	1	01	01	H1036_151_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	153	0	1	01	01	H1036_153_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	153	0	1	01	01	H1036_153_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	153	0	1	01	01	H1036_153_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	153	0	1	01	01	H1036_153_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	153	0	1	01	01	H1036_153_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	153	0	1	01	01	H1036_153_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	153	0	1	01	01	H1036_153_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	157	0	1	01	01	H1036_157_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	157	0	1	01	01	H1036_157_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	157	0	1	01	01	H1036_157_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	157	0	1	01	01	H1036_157_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	157	0	1	01	01	H1036_157_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	157	0	1	01	01	H1036_157_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									100.00		300.00				85.00		245.00				85.00				85.00		2.83				3.33	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	157	0	1	01	01	H1036_157_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	160	0	1	01	01	H1036_160_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	160	0	1	01	01	H1036_160_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	160	0	1	01	01	H1036_160_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	160	0	1	01	01	H1036_160_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	160	0	1	01	01	H1036_160_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1036	160	0	1	01	01	H1036_160_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	160	0	1	01	01	H1036_160_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									100.00		300.00				35.00		95.00				35.00				35.00		1.17				3.33	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	160	0	1	01	01	H1036_160_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									100.00		300.00				35.00		95.00				35.00				35.00		1.17				3.33	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	160	0	1	01	01	H1036_160_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	160	0	1	01	01	H1036_160_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	160	0	1	01	01	H1036_160_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	160	0	1	01	01	H1036_160_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	217	0	1	01	01	H1036_217_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	217	0	1	01	01	H1036_217_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	217	0	1	01	01	H1036_217_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	217	0	1	01	01	H1036_217_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	217	0	1	01	01	H1036_217_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	217	0	1	01	01	H1036_217_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	217	0	1	01	01	H1036_217_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	219	0	1	01	01	H1036_219_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	219	0	1	01	01	H1036_219_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	219	0	1	01	01	H1036_219_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	219	0	1	01	01	H1036_219_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	219	0	1	01	01	H1036_219_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	219	0	1	01	01	H1036_219_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	219	0	1	01	01	H1036_219_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	229	0	1	01	01	H1036_229_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	229	0	1	01	01	H1036_229_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	229	0	1	01	01	H1036_229_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H1036	229	0	1	01	01	H1036_229_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	229	0	1	01	01	H1036_229_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	230	0	1	01	01	H1036_230_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	230	0	1	01	01	H1036_230_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	230	0	1	01	01	H1036_230_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									15.00		45.00				0.00		0.00				0.00				0.00		0.00				0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				15.00		45.00	0.00		0.00	0.00		0.00
H1036	230	0	1	01	01	H1036_230_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									15.00		45.00				0.00		0.00				0.00				0.00		0.00				0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	230	0	1	01	01	H1036_230_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H1036	230	0	1	01	01	H1036_230_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	230	0	1	01	01	H1036_230_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	233	0	1	02	01	H1036_233_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	233	0	1	02	01	H1036_233_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	233	0	1	02	01	H1036_233_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	233	0	1	02	01	H1036_233_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	233	0	1	02	01	H1036_233_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	234	0	1	01	01	H1036_234_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	234	0	1	01	01	H1036_234_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1036	234	0	1	01	01	H1036_234_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	234	0	1	01	01	H1036_234_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1036	234	0	1	01	01	H1036_234_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	42.00		126.00																									47.00		141.00				42.00		116.00				42.00				42.00		1.40				1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	234	0	1	01	01	H1036_234_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	234	0	1	01	01	H1036_234_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	234	0	1	01	01	H1036_234_0	7			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	236	0	1	01	01	H1036_236_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	236	0	1	01	01	H1036_236_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	236	0	1	01	01	H1036_236_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	236	0	1	01	01	H1036_236_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	236	0	1	01	01	H1036_236_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	42.00		126.00																									47.00		141.00				42.00		116.00				42.00				42.00		1.40				1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	236	0	1	01	01	H1036_236_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	236	0	1	01	01	H1036_236_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	265	1	1	01	01	H1036_265_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	265	1	1	01	01	H1036_265_1	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	265	1	1	01	01	H1036_265_1	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	265	1	1	01	01	H1036_265_1	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	265	1	1	01	01	H1036_265_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	265	1	1	01	01	H1036_265_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	265	1	1	01	01	H1036_265_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	265	2	1	01	01	H1036_265_2	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	265	2	1	01	01	H1036_265_2	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	265	2	1	01	01	H1036_265_2	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	265	2	1	01	01	H1036_265_2	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	265	2	1	01	01	H1036_265_2	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	265	2	1	01	01	H1036_265_2	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	265	2	1	01	01	H1036_265_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	266	0	1	01	01	H1036_266_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	266	0	1	01	01	H1036_266_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	266	0	1	01	01	H1036_266_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	266	0	1	01	01	H1036_266_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	266	0	1	01	01	H1036_266_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	266	0	1	01	01	H1036_266_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	266	0	1	01	01	H1036_266_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	269	0	1	01	01	H1036_269_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	269	0	1	01	01	H1036_269_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	269	0	1	01	01	H1036_269_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	269	0	1	01	01	H1036_269_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	269	0	1	01	01	H1036_269_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	269	0	1	01	01	H1036_269_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	269	0	1	01	01	H1036_269_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	270	0	1	01	01	H1036_270_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	270	0	1	01	01	H1036_270_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	270	0	1	01	01	H1036_270_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	270	0	1	01	01	H1036_270_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	270	0	1	01	01	H1036_270_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	270	0	1	01	01	H1036_270_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	270	0	1	01	01	H1036_270_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	271	0	1	01	01	H1036_271_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	271	0	1	01	01	H1036_271_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	271	0	1	01	01	H1036_271_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	271	0	1	01	01	H1036_271_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	271	0	1	01	01	H1036_271_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	271	0	1	01	01	H1036_271_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	271	0	1	01	01	H1036_271_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	278	0	1	01	01	H1036_278_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	278	0	1	01	01	H1036_278_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	278	0	1	01	01	H1036_278_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	278	0	1	01	01	H1036_278_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	278	0	1	01	01	H1036_278_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	278	0	1	01	01	H1036_278_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	278	0	1	01	01	H1036_278_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	286	0	1	01	01	H1036_286_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	286	0	1	01	01	H1036_286_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	286	0	1	01	01	H1036_286_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	286	0	1	01	01	H1036_286_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	286	0	1	01	01	H1036_286_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	291	0	1	02	01	H1036_291_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	291	0	1	02	01	H1036_291_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	291	0	1	02	01	H1036_291_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	291	0	1	02	01	H1036_291_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	291	0	1	02	01	H1036_291_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	292	0	1	01	01	H1036_292_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	292	0	1	01	01	H1036_292_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	292	0	1	01	01	H1036_292_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	292	0	1	01	01	H1036_292_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	292	0	1	01	01	H1036_292_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	295	0	1	01	01	H1036_295_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	295	0	1	01	01	H1036_295_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	295	0	1	01	01	H1036_295_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	295	0	1	01	01	H1036_295_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	295	0	1	01	01	H1036_295_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H1036	295	0	1	01	01	H1036_295_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	90.00		270.00																									100.00		300.00				90.00		260.00				90.00				90.00		3.00				3.33	3.00	2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	295	0	1	01	01	H1036_295_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	297	0	1	01	01	H1036_297_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	297	0	1	01	01	H1036_297_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	297	0	1	01	01	H1036_297_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	297	0	1	01	01	H1036_297_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	297	0	1	01	01	H1036_297_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	40.00		120.00																									45.00		135.00				40.00		110.00				40.00				40.00		1.33				1.50	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	297	0	1	01	01	H1036_297_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	85.00		255.00																									90.00		270.00				85.00		245.00				85.00				85.00		2.83				3.00	2.83	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	297	0	1	01	01	H1036_297_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	298	0	1	01	01	H1036_298_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	298	0	1	01	01	H1036_298_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1036	298	0	1	01	01	H1036_298_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									47.00		141.00				35.00		95.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	298	0	1	01	01	H1036_298_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	298	0	1	01	01	H1036_298_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	299	0	1	01	01	H1036_299_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	299	0	1	01	01	H1036_299_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	299	0	1	01	01	H1036_299_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	299	0	1	01	01	H1036_299_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	299	0	1	01	01	H1036_299_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	299	0	1	01	01	H1036_299_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	299	0	1	01	01	H1036_299_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	299	0	1	01	01	H1036_299_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	299	0	1	01	01	H1036_299_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	299	0	1	01	01	H1036_299_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	299	0	1	01	01	H1036_299_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	299	0	1	01	01	H1036_299_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	300	0	1	01	01	H1036_300_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	300	0	1	01	01	H1036_300_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	300	0	1	01	01	H1036_300_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	300	0	1	01	01	H1036_300_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	300	0	1	01	01	H1036_300_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	300	0	1	01	01	H1036_300_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	300	0	1	01	01	H1036_300_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	300	0	1	01	01	H1036_300_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	300	0	1	01	01	H1036_300_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	300	0	1	01	01	H1036_300_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	300	0	1	01	01	H1036_300_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	300	0	1	01	01	H1036_300_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	301	0	1	01	01	H1036_301_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	301	0	1	01	01	H1036_301_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	301	0	1	01	01	H1036_301_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	301	0	1	01	01	H1036_301_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	301	0	1	01	01	H1036_301_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	301	0	1	01	01	H1036_301_0	7			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	301	0	1	01	01	H1036_301_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	301	0	1	01	01	H1036_301_0	7			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	301	0	1	01	01	H1036_301_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	301	0	1	01	01	H1036_301_0	7			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	301	0	1	01	01	H1036_301_0	7			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	301	0	1	01	01	H1036_301_0	7			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	302	0	1	01	01	H1036_302_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	302	0	1	01	01	H1036_302_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	302	0	1	01	01	H1036_302_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	302	0	1	01	01	H1036_302_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	302	0	1	01	01	H1036_302_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	302	0	1	01	01	H1036_302_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	302	0	1	01	01	H1036_302_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	302	0	1	01	01	H1036_302_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	302	0	1	01	01	H1036_302_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	302	0	1	01	01	H1036_302_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	302	0	1	01	01	H1036_302_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	302	0	1	01	01	H1036_302_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	305	0	1	01	01	H1036_305_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									5.00		15.00				0.00		0.00				0.00				0.00		0.00				0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				5.00		15.00	0.00		0.00	0.00		0.00
H1036	305	0	1	01	01	H1036_305_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	305	0	1	01	01	H1036_305_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	305	0	1	01	01	H1036_305_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	80.00		240.00																									100.00		300.00				80.00		230.00				80.00				80.00		2.67				3.33	2.67	2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	305	0	1	01	01	H1036_305_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	306	0	1	01	01	H1036_306_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	306	0	1	01	01	H1036_306_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1036	306	0	1	01	01	H1036_306_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	306	0	1	01	01	H1036_306_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1036	306	0	1	01	01	H1036_306_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	306	0	1	01	01	H1036_306_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	306	0	1	01	01	H1036_306_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1036	308	0	1	01	01	H1036_308_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	308	0	1	01	01	H1036_308_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1036	308	0	1	01	01	H1036_308_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	308	0	1	01	01	H1036_308_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1036	308	0	1	01	01	H1036_308_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	308	0	1	01	01	H1036_308_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	308	0	1	01	01	H1036_308_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	308	0	1	01	01	H1036_308_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	310	0	1	01	01	H1036_310_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	310	0	1	01	01	H1036_310_0	4			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	310	0	1	01	01	H1036_310_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	310	0	1	01	01	H1036_310_0	4			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	310	0	1	01	01	H1036_310_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1036	310	0	1	01	01	H1036_310_0	4			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	310	0	1	01	01	H1036_310_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									100.00		300.00				35.00		95.00				35.00				35.00		1.17				3.33	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	310	0	1	01	01	H1036_310_0	4			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									100.00		300.00				35.00		95.00				35.00				35.00		1.17				3.33	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	310	0	1	01	01	H1036_310_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	310	0	1	01	01	H1036_310_0	4			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	310	0	1	01	01	H1036_310_0	4			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	310	0	1	01	01	H1036_310_0	4			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	311	0	1	01	01	H1036_311_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	311	0	1	01	01	H1036_311_0	4			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	311	0	1	01	01	H1036_311_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	311	0	1	01	01	H1036_311_0	4			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	311	0	1	01	01	H1036_311_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00
H1036	311	0	1	01	01	H1036_311_0	4			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									47.00		141.00				5.00		5.00				5.00				5.00		0.17				1.57	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	311	0	1	01	01	H1036_311_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									100.00		300.00				35.00		95.00				35.00				35.00		1.17				3.33	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H1036	311	0	1	01	01	H1036_311_0	4			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	35.00		105.00																									100.00		300.00				35.00		95.00				35.00				35.00		1.17				3.33	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	311	0	1	01	01	H1036_311_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	311	0	1	01	01	H1036_311_0	4			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	311	0	1	01	01	H1036_311_0	4			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	311	0	1	01	01	H1036_311_0	4			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	312	0	1	01	01	H1036_312_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	312	0	1	01	01	H1036_312_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	312	0	1	01	01	H1036_312_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	312	0	1	01	01	H1036_312_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	312	0	1	01	01	H1036_312_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	312	0	1	01	01	H1036_312_0	5			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	312	0	1	01	01	H1036_312_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	312	0	1	01	01	H1036_312_0	5			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	312	0	1	01	01	H1036_312_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	312	0	1	01	01	H1036_312_0	5			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	312	0	1	01	01	H1036_312_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	312	0	1	01	01	H1036_312_0	5			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	313	0	1	01	01	H1036_313_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	313	0	1	01	01	H1036_313_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	313	0	1	01	01	H1036_313_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	313	0	1	01	01	H1036_313_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	313	0	1	01	01	H1036_313_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	313	0	1	01	01	H1036_313_0	5			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	313	0	1	01	01	H1036_313_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	313	0	1	01	01	H1036_313_0	5			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	313	0	1	01	01	H1036_313_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	313	0	1	01	01	H1036_313_0	5			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	313	0	1	01	01	H1036_313_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	313	0	1	01	01	H1036_313_0	5			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	315	0	1	01	01	H1036_315_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	315	0	1	01	01	H1036_315_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	315	0	1	01	01	H1036_315_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	315	0	1	01	01	H1036_315_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	315	0	1	01	01	H1036_315_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	315	0	1	01	01	H1036_315_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	315	0	1	01	01	H1036_315_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	315	0	1	01	01	H1036_315_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	315	0	1	01	01	H1036_315_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	315	0	1	01	01	H1036_315_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	315	0	1	01	01	H1036_315_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	315	0	1	01	01	H1036_315_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1036	316	0	1	01	01	H1036_316_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1036	316	0	1	01	01	H1036_316_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	316	0	1	01	01	H1036_316_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1036	316	0	1	01	01	H1036_316_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1036	316	0	1	01	01	H1036_316_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	316	0	1	01	01	H1036_316_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	316	0	1	01	01	H1036_316_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1036	316	0	1	01	01	H1036_316_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	316	0	1	01	01	H1036_316_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1036	316	0	1	01	01	H1036_316_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1036	316	0	1	01	01	H1036_316_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1036	316	0	1	01	01	H1036_316_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1045	001	0	1	01	01	H1045_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	001	0	1	01	01	H1045_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	001	0	1	01	01	H1045_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	001	0	1	01	01	H1045_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	001	0	1	01	01	H1045_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H1045	001	0	1	01	01	H1045_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	40.00		120.00																											120.00						110.00				40.00				40.00		1.33						1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	001	0	1	01	01	H1045_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				591.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	005	0	1	01	01	H1045_005_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	005	0	1	01	01	H1045_005_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	005	0	1	01	01	H1045_005_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	005	0	1	01	01	H1045_005_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	005	0	1	01	01	H1045_005_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	25.00		75.00																											75.00						65.00				25.00				25.00		0.83						0.80	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H1045	005	0	1	01	01	H1045_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	005	0	1	01	01	H1045_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				724.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	018	0	1	01	01	H1045_018_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	018	0	1	01	01	H1045_018_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	018	0	1	01	01	H1045_018_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	018	0	1	01	01	H1045_018_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	018	0	1	01	01	H1045_018_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	3.00		9.00																											9.00						9.00				3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		9.00						9.00			9.00	3.00		3.00
H1045	018	0	1	01	01	H1045_018_0	6			Preferred Brand	4	11	1	2	3	3	110		01		100	1	30		100				2	2						100	30		31	3.00		9.00																											9.00						9.00				3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	018	0	1	01	01	H1045_018_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	018	0	1	01	01	H1045_018_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				467.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	025	0	1	02	01	H1045_025_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	025	0	1	02	01	H1045_025_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	025	0	1	02	01	H1045_025_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	025	0	1	02	01	H1045_025_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	025	0	1	02	01	H1045_025_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	025	0	1	02	01	H1045_025_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	025	0	1	02	01	H1045_025_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				541.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	026	0	1	02	01	H1045_026_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	026	0	1	02	01	H1045_026_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	026	0	1	02	01	H1045_026_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	6.00		18.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	026	0	1	02	01	H1045_026_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	6.00		18.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	026	0	1	02	01	H1045_026_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	026	0	1	02	01	H1045_026_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	026	0	1	02	01	H1045_026_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				511.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	028	0	1	02	01	H1045_028_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	028	0	1	02	01	H1045_028_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	028	0	1	02	01	H1045_028_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	028	0	1	02	01	H1045_028_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	028	0	1	02	01	H1045_028_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	028	0	1	02	01	H1045_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	028	0	1	02	01	H1045_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				555.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	030	0	1	02	01	H1045_030_0	9			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	030	0	1	02	01	H1045_030_0	9			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	030	0	1	02	01	H1045_030_0	9			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	030	0	1	02	01	H1045_030_0	9			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	030	0	1	02	01	H1045_030_0	9			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	030	0	1	02	01	H1045_030_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	030	0	1	02	01	H1045_030_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				525.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	031	0	1	02	01	H1045_031_0	9			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	031	0	1	02	01	H1045_031_0	9			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	031	0	1	02	01	H1045_031_0	9			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	031	0	1	02	01	H1045_031_0	9			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	031	0	1	02	01	H1045_031_0	9			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	031	0	1	02	01	H1045_031_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	031	0	1	02	01	H1045_031_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				583.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	033	0	1	02	01	H1045_033_0	8			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	033	0	1	02	01	H1045_033_0	8			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	033	0	1	02	01	H1045_033_0	8			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	033	0	1	02	01	H1045_033_0	8			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	033	0	1	02	01	H1045_033_0	8			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	033	0	1	02	01	H1045_033_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	033	0	1	02	01	H1045_033_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				462.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	034	0	1	02	01	H1045_034_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	034	0	1	02	01	H1045_034_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	034	0	1	02	01	H1045_034_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	034	0	1	02	01	H1045_034_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	034	0	1	02	01	H1045_034_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	034	0	1	02	01	H1045_034_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	034	0	1	02	01	H1045_034_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				546.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	036	0	1	02	01	H1045_036_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	036	0	1	02	01	H1045_036_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	036	0	1	02	01	H1045_036_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	6.00		18.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	036	0	1	02	01	H1045_036_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	6.00		18.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	036	0	1	02	01	H1045_036_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	036	0	1	02	01	H1045_036_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	036	0	1	02	01	H1045_036_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				672.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	037	0	1	01	01	H1045_037_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	037	0	1	01	01	H1045_037_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	037	0	1	01	01	H1045_037_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	037	0	1	01	01	H1045_037_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	037	0	1	01	01	H1045_037_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	15.00		45.00																											45.00						35.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00						45.00			35.00	15.00		15.00
H1045	037	0	1	01	01	H1045_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	037	0	1	01	01	H1045_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				548.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	041	0	1	02	01	H1045_041_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	041	0	1	02	01	H1045_041_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	041	0	1	02	01	H1045_041_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	041	0	1	02	01	H1045_041_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	041	0	1	02	01	H1045_041_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	041	0	1	02	01	H1045_041_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	041	0	1	02	01	H1045_041_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				544.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	042	0	1	02	01	H1045_042_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	042	0	1	02	01	H1045_042_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	042	0	1	02	01	H1045_042_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	042	0	1	02	01	H1045_042_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	042	0	1	02	01	H1045_042_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	042	0	1	02	01	H1045_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	042	0	1	02	01	H1045_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				505.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	043	0	1	02	01	H1045_043_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	043	0	1	02	01	H1045_043_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	043	0	1	02	01	H1045_043_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	043	0	1	02	01	H1045_043_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	043	0	1	02	01	H1045_043_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	043	0	1	02	01	H1045_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	043	0	1	02	01	H1045_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				512.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	045	0	1	02	01	H1045_045_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	045	0	1	02	01	H1045_045_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	045	0	1	02	01	H1045_045_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	045	0	1	02	01	H1045_045_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	045	0	1	02	01	H1045_045_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	045	0	1	02	01	H1045_045_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	045	0	1	02	01	H1045_045_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				597.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	1	1	02	01	H1045_048_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	1	1	02	01	H1045_048_1	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	048	1	1	02	01	H1045_048_1	7			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	1	1	02	01	H1045_048_1	7			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	048	1	1	02	01	H1045_048_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00	25.00		65.00			75.00			65.00	25.00		25.00
H1045	048	1	1	02	01	H1045_048_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H1045	048	1	1	02	01	H1045_048_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											500.00	33						624.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	2	1	02	01	H1045_048_2	6			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	2	1	02	01	H1045_048_2	6			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	048	2	1	02	01	H1045_048_2	6			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	2	1	02	01	H1045_048_2	6			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	048	2	1	02	01	H1045_048_2	6			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00	25.00		65.00			75.00			65.00	25.00		25.00
H1045	048	2	1	02	01	H1045_048_2	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H1045	048	2	1	02	01	H1045_048_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											500.00	33						624.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	3	1	02	01	H1045_048_3	6			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	3	1	02	01	H1045_048_3	6			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	048	3	1	02	01	H1045_048_3	6			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	3	1	02	01	H1045_048_3	6			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	048	3	1	02	01	H1045_048_3	6			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00	25.00		65.00			75.00			65.00	25.00		25.00
H1045	048	3	1	02	01	H1045_048_3	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H1045	048	3	1	02	01	H1045_048_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											500.00	33						624.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	4	1	02	01	H1045_048_4	6			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	4	1	02	01	H1045_048_4	6			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	048	4	1	02	01	H1045_048_4	6			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	048	4	1	02	01	H1045_048_4	6			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1045	048	4	1	02	01	H1045_048_4	6			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00	25.00		65.00			75.00			65.00	25.00		25.00
H1045	048	4	1	02	01	H1045_048_4	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H1045	048	4	1	02	01	H1045_048_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											500.00	33						624.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	055	0	1	02	01	H1045_055_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	055	0	1	02	01	H1045_055_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	055	0	1	02	01	H1045_055_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	055	0	1	02	01	H1045_055_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	055	0	1	02	01	H1045_055_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	055	0	1	02	01	H1045_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	055	0	1	02	01	H1045_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				632.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	056	0	1	02	01	H1045_056_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	056	0	1	02	01	H1045_056_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1045	056	0	1	02	01	H1045_056_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1045	056	0	1	02	01	H1045_056_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1045	056	0	1	02	01	H1045_056_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	40.00		120.00																											120.00						110.00				40.00				40.00		1.33						1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	056	0	1	02	01	H1045_056_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	90.00		270.00																											270.00						260.00				90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1045	056	0	1	02	01	H1045_056_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				593.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	001	0	1	02	01	H1099_001_0	4			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H1099	001	0	1	02	01	H1099_001_0	4			Preferred Generic	4	11	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1099	001	0	1	02	01	H1099_001_0	4			Generic	4	11	1	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	001	0	1	02	01	H1099_001_0	4			Generic	4	11	1	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1099	001	0	1	02	01	H1099_001_0	4			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								45.00	90.00	135.00					40.00	80.00	120.00							112.50																45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	001	0	1	02	01	H1099_001_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								90.00	180.00	270.00					80.00	160.00	240.00							225.00																90.00				90.00			3.00	2.67				2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	001	0	1	02	01	H1099_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1542.87	33						1003.64	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00									35.00		35.00
H1099	006	0	1	01	01	H1099_006_0	4			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H1099	006	0	1	01	01	H1099_006_0	4			Preferred Generic	4	11	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1099	006	0	1	01	01	H1099_006_0	4			Generic	4	11	1	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	006	0	1	01	01	H1099_006_0	4			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								45.00	90.00	135.00					40.00	80.00	120.00							112.50																45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	006	0	1	01	01	H1099_006_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								90.00	180.00	270.00					80.00	160.00	240.00							225.00																90.00				90.00			3.00	2.67				2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	006	0	1	01	01	H1099_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1476.96	33						922.43	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00									35.00		35.00
H1099	014	0	1	01	01	H1099_014_0	4			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H1099	014	0	1	01	01	H1099_014_0	4			Preferred Generic	4	11	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1099	014	0	1	01	01	H1099_014_0	4			Generic	4	11	1	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	014	0	1	01	01	H1099_014_0	4			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								45.00	90.00	135.00					40.00	80.00	120.00							112.50																45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	014	0	1	01	01	H1099_014_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								90.00	180.00	270.00					80.00	160.00	240.00							225.00																90.00				90.00			3.00	2.67				2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	014	0	1	01	01	H1099_014_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1246.13	33						1227.57	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00									35.00		35.00
H1099	016	0	1	01	01	H1099_016_0	4			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H1099	016	0	1	01	01	H1099_016_0	4			Preferred Generic	4	11	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1099	016	0	1	01	01	H1099_016_0	4			Generic	4	11	1	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	016	0	1	01	01	H1099_016_0	4			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H1099	016	0	1	01	01	H1099_016_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								95.00	190.00	285.00					90.00	180.00	270.00							225.00																95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1099	016	0	1	01	01	H1099_016_0	4			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1857.87	33						1007.51	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00									35.00		35.00
H1109	005	0	1	01	01	H1109_005_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1109	005	0	1	01	01	H1109_005_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1109	005	0	1	01	01	H1109_005_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1109	005	0	1	01	01	H1109_005_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1109	005	0	1	01	01	H1109_005_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1109	005	0	1	01	01	H1109_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1109	005	0	1	01	01	H1109_005_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											708.26	33						543.45	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1112	038	0	1	01	01	H1112_038_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	038	0	1	01	01	H1112_038_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	038	0	1	01	01	H1112_038_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1112	038	0	1	01	01	H1112_038_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.98	41	41	41				97.98	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1112	038	0	1	01	01	H1112_038_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1112	038	0	1	01	01	H1112_038_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	038	0	1	01	01	H1112_038_0	8			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1112	039	0	1	01	01	H1112_039_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	039	0	1	01	01	H1112_039_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	039	0	1	01	01	H1112_039_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1112	039	0	1	01	01	H1112_039_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.62	50	50	50				87.62	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1112	039	0	1	01	01	H1112_039_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1112	039	0	1	01	01	H1112_039_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	039	0	1	01	01	H1112_039_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1112	042	0	1	01	01	H1112_042_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	042	0	1	01	01	H1112_042_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	042	0	1	01	01	H1112_042_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1112	042	0	1	01	01	H1112_042_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.33	50	50	50				97.33	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1112	042	0	1	01	01	H1112_042_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1112	042	0	1	01	01	H1112_042_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	043	0	1	01	01	H1112_043_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	043	0	1	01	01	H1112_043_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	043	0	1	01	01	H1112_043_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1112	043	0	1	01	01	H1112_043_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.84	45	45	45				99.84	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1112	043	0	1	01	01	H1112_043_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1112	043	0	1	01	01	H1112_043_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	044	0	1	01	01	H1112_044_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	044	0	1	01	01	H1112_044_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	044	0	1	01	01	H1112_044_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1112	044	0	1	01	01	H1112_044_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.01	50	50	50				87.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1112	044	0	1	01	01	H1112_044_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1112	044	0	1	01	01	H1112_044_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1112	044	0	1	01	01	H1112_044_0	8			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1170	002	0	1	01	01	H1170_002_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	002	0	1	01	01	H1170_002_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	002	0	1	01	01	H1170_002_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	002	0	1	01	01	H1170_002_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	002	0	1	01	01	H1170_002_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	002	0	1	01	01	H1170_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.16			3.16			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	002	0	1	01	01	H1170_002_0	8			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	002	0	1	01	01	H1170_002_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	002	0	1	01	01	H1170_002_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	008	0	1	01	01	H1170_008_0	8		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	008	0	1	01	01	H1170_008_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	0.00	0.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00				14.00	0.00	0.00				14.00		14.00
H1170	008	0	1	01	01	H1170_008_0	8		N	Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	008	0	1	01	01	H1170_008_0	8		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	008	0	1	01	01	H1170_008_0	8		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	008	0	1	01	01	H1170_008_0	8		N	Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	009	0	1	01	01	H1170_009_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	009	0	1	01	01	H1170_009_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	009	0	1	01	01	H1170_009_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	009	0	1	01	01	H1170_009_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	009	0	1	01	01	H1170_009_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	009	0	1	01	01	H1170_009_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.16			3.16			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	009	0	1	01	01	H1170_009_0	8			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	009	0	1	01	01	H1170_009_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	009	0	1	01	01	H1170_009_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	010	0	1	01	01	H1170_010_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	010	0	1	01	01	H1170_010_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	010	0	1	01	01	H1170_010_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	0.00	0.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				0.00	0.00	0.00				6.00		6.00
H1170	010	0	1	01	01	H1170_010_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	0.00	0.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	010	0	1	01	01	H1170_010_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	010	0	1	01	01	H1170_010_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.16			3.16			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	010	0	1	01	01	H1170_010_0	8			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	010	0	1	01	01	H1170_010_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	010	0	1	01	01	H1170_010_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	011	0	1	01	01	H1170_011_0	8		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	011	0	1	01	01	H1170_011_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	0.00	0.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00				14.00	0.00	0.00				14.00		14.00
H1170	011	0	1	01	01	H1170_011_0	8		N	Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	011	0	1	01	01	H1170_011_0	8		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	011	0	1	01	01	H1170_011_0	8		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	011	0	1	01	01	H1170_011_0	8		N	Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	012	0	1	01	01	H1170_012_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	012	0	1	01	01	H1170_012_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	012	0	1	01	01	H1170_012_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	0.00	0.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				6.00	0.00	0.00				6.00		6.00
H1170	012	0	1	01	01	H1170_012_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	0.00	0.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	012	0	1	01	01	H1170_012_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	012	0	1	01	01	H1170_012_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.16			3.16			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	012	0	1	01	01	H1170_012_0	8			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	012	0	1	01	01	H1170_012_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	012	0	1	01	01	H1170_012_0	8			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	013	0	1	02	01	H1170_013_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	013	0	1	02	01	H1170_013_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	013	0	1	02	01	H1170_013_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1170	013	0	1	02	01	H1170_013_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1170	013	0	1	02	01	H1170_013_0	9			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1170	013	0	1	02	01	H1170_013_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.16			3.16			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	013	0	1	02	01	H1170_013_0	9			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1170	013	0	1	02	01	H1170_013_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1170	013	0	1	02	01	H1170_013_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1189	002	0	1	01	01	H1189_002_0	11			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	2			90				30		34	4.00		12.00																					0.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	002	0	1	01	01	H1189_002_0	11			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	10.00		30.00																					0.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	002	0	1	01	01	H1189_002_0	11			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	2			90				30		34	47.00		141.00																					141.00																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H1189	002	0	1	01	01	H1189_002_0	11			Non-Preferred Drug	4	10	1	2	4	1	110		01	100		1	30		90				1	2			90				30		34	100.00		300.00																					300.00																100.00				100.00		3.33						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	002	0	1	01	01	H1189_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				845.39	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	002	0	1	01	01	H1189_002_0	11			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	002	0	1	01	01	H1189_002_0	11			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1189	003	0	1	01	01	H1189_003_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		34	4.00		12.00																					0.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	003	0	1	01	01	H1189_003_0	10			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	10.00		30.00																					0.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	003	0	1	01	01	H1189_003_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	2			90				30		34	47.00		141.00																					141.00																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H1189	003	0	1	01	01	H1189_003_0	10			Non-Preferred Drug	4	10	1	2	4	1	110		01	100		1	30		90				1	2			90				30		34	100.00		300.00																					300.00																100.00				100.00		3.33						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	003	0	1	01	01	H1189_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				1060.16	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	003	0	1	01	01	H1189_003_0	10			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	003	0	1	01	01	H1189_003_0	10			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1189	004	0	1	01	01	H1189_004_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	2			90				30		34	4.00		12.00																					0.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	004	0	1	01	01	H1189_004_0	10			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	10.00		30.00																					0.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	004	0	1	01	01	H1189_004_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	2			90				30		34	47.00		141.00																					141.00																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H1189	004	0	1	01	01	H1189_004_0	10			Non-Preferred Drug	4	10	1	2	4	1	110		01	100		1	30		90				1	2			90				30		34	100.00		300.00																					300.00																100.00				100.00		3.33						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	004	0	1	01	01	H1189_004_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				1181.35	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	004	0	1	01	01	H1189_004_0	10			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	004	0	1	01	01	H1189_004_0	10			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1189	005	0	1	01	01	H1189_005_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	2			90				30		34	4.00		12.00																					0.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	005	0	1	01	01	H1189_005_0	10			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	10.00		30.00																					0.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	005	0	1	01	01	H1189_005_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	2			90				30		34	47.00		141.00																					141.00																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H1189	005	0	1	01	01	H1189_005_0	10			Non-Preferred Drug	4	10	1	2	4	1	110		01	100		1	30		90				1	2			90				30		34	100.00		300.00																					300.00																100.00				100.00		3.33						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	005	0	1	01	01	H1189_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				1186.63	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	005	0	1	01	01	H1189_005_0	10			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	005	0	1	01	01	H1189_005_0	10			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1189	009	0	1	01	01	H1189_009_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	2			90				30		34	4.00		12.00																					0.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	009	0	1	01	01	H1189_009_0	10			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	10.00		30.00																					0.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	009	0	1	01	01	H1189_009_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	2			90				30		34	47.00		141.00																					141.00																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H1189	009	0	1	01	01	H1189_009_0	10			Non-Preferred Drug	4	10	1	2	4	1	110		01	100		1	30		90				1	2			90				30		34	100.00		300.00																					300.00																100.00				100.00		3.33						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	009	0	1	01	01	H1189_009_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				1186.63	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	009	0	1	01	01	H1189_009_0	10			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	009	0	1	01	01	H1189_009_0	10			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1189	010	0	1	01	01	H1189_010_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	2			90				30		34	4.00		12.00																					0.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	010	0	1	01	01	H1189_010_0	10			Generic	4	01	1	2	2	1	110		01	100		1	30		90				1	2			90				30		34	10.00		30.00																					0.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	010	0	1	01	01	H1189_010_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				1	2			90				30		34	47.00		141.00																					141.00																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H1189	010	0	1	01	01	H1189_010_0	10			Non-Preferred Drug	4	10	1	2	4	1	110		01	100		1	30		90				1	2			90				30		34	100.00		300.00																					300.00																100.00				100.00		3.33						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	010	0	1	01	01	H1189_010_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				1186.63	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	010	0	1	01	01	H1189_010_0	10			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1189	010	0	1	01	01	H1189_010_0	10			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		90				1	2			90				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1206	001	0	1	02	01	H1206_001_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1206	001	0	1	02	01	H1206_001_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1206	001	0	1	02	01	H1206_001_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1206	001	0	1	02	01	H1206_001_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1206	001	0	1	02	01	H1206_001_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1206	001	0	1	02	01	H1206_001_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1206	001	0	1	02	01	H1206_001_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.66	30						614.28	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1206	002	0	1	02	01	H1206_002_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1206	002	0	1	02	01	H1206_002_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1206	002	0	1	02	01	H1206_002_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1206	002	0	1	02	01	H1206_002_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1206	002	0	1	02	01	H1206_002_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1206	002	0	1	02	01	H1206_002_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1206	002	0	1	02	01	H1206_002_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.66	30						614.28	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1215	002	0	1	01	01	H1215_002_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1215	002	0	1	01	01	H1215_002_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	27.00					4.00	8.00	12.00											9.00	18.00	27.00				4.00	8.00	0.00				9.00				9.00			0.30	0.13		0.30	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1215	002	0	1	01	01	H1215_002_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1215	002	0	1	01	01	H1215_002_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.85	50	50	50				84.85	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1215	002	0	1	01	01	H1215_002_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1215	002	0	1	01	01	H1215_002_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1215	003	0	1	01	01	H1215_003_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1215	003	0	1	01	01	H1215_003_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1215	003	0	1	01	01	H1215_003_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1215	003	0	1	01	01	H1215_003_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											78.01	50	50	50				78.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1215	003	0	1	01	01	H1215_003_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1215	003	0	1	01	01	H1215_003_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1225	001	0	1	01	01	H1225_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1225	001	0	1	01	01	H1225_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1225	001	0	1	01	01	H1225_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	15.00	20.00																			10.00	15.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	15.00	20.00				10.00	15.00	20.00				10.00		10.00
H1225	001	0	1	01	01	H1225_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	70.50	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H1225	001	0	1	01	01	H1225_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	150.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H1225	001	0	1	01	01	H1225_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1230	001	0	1	01	01	H1230_001_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				0.00	0.00	0.00				6.00		6.00
H1230	001	0	1	01	01	H1230_001_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	001	0	1	01	01	H1230_001_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00				14.00	28.00	28.00				14.00		14.00
H1230	001	0	1	01	01	H1230_001_0	13			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	001	0	1	01	01	H1230_001_0	13			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1230	001	0	1	01	01	H1230_001_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	001	0	1	01	01	H1230_001_0	13			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	001	0	1	01	01	H1230_001_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1230	001	0	1	01	01	H1230_001_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	003	0	1	01	01	H1230_003_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				0.00	0.00	0.00				6.00		6.00
H1230	003	0	1	01	01	H1230_003_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	003	0	1	01	01	H1230_003_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00				14.00	28.00	28.00				14.00		14.00
H1230	003	0	1	01	01	H1230_003_0	13			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	003	0	1	01	01	H1230_003_0	13			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1230	003	0	1	01	01	H1230_003_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	003	0	1	01	01	H1230_003_0	13			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	003	0	1	01	01	H1230_003_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1230	003	0	1	01	01	H1230_003_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	013	0	1	01	01	H1230_013_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				0.00	0.00	0.00				6.00		6.00
H1230	013	0	1	01	01	H1230_013_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	013	0	1	01	01	H1230_013_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00				14.00	28.00	28.00				14.00		14.00
H1230	013	0	1	01	01	H1230_013_0	13			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	013	0	1	01	01	H1230_013_0	13			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1230	013	0	1	01	01	H1230_013_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	013	0	1	01	01	H1230_013_0	13			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	013	0	1	01	01	H1230_013_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1230	013	0	1	01	01	H1230_013_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	014	0	1	01	01	H1230_014_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													6.00	12.00	18.00				0.00	0.00	0.00				6.00		6.00
H1230	014	0	1	01	01	H1230_014_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	014	0	1	01	01	H1230_014_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00				14.00	28.00	28.00				14.00		14.00
H1230	014	0	1	01	01	H1230_014_0	13			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	28.00																14.00				14.00		0.46			0.46			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1230	014	0	1	01	01	H1230_014_0	13			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1230	014	0	1	01	01	H1230_014_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	014	0	1	01	01	H1230_014_0	13			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1230	014	0	1	01	01	H1230_014_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H1230	014	0	1	01	01	H1230_014_0	13			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H1248	004	0	1	04	01	H1248_004_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1248	004	0	1	04	01	H1248_004_0	8			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1248	004	0	1	04	01	H1248_004_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1248	004	0	1	04	01	H1248_004_0	8			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1248	004	0	1	04	01	H1248_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1248	004	0	1	04	01	H1248_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1248	004	0	1	04	01	H1248_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1604.62	33						685.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1248	007	0	1	04	01	H1248_007_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1248	007	0	1	04	01	H1248_007_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1248	007	0	1	04	01	H1248_007_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1248	007	0	1	04	01	H1248_007_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1248	007	0	1	04	01	H1248_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1248	007	0	1	04	01	H1248_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1248	007	0	1	04	01	H1248_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											983.59	29						815.15	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1277	001	0	1	02	01	H1277_001_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	001	0	1	02	01	H1277_001_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	001	0	1	02	01	H1277_001_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1277	001	0	1	02	01	H1277_001_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	001	0	1	02	01	H1277_001_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	002	0	1	02	01	H1277_002_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	002	0	1	02	01	H1277_002_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	002	0	1	02	01	H1277_002_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1277	002	0	1	02	01	H1277_002_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	002	0	1	02	01	H1277_002_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1277	004	0	1	02	01	H1277_004_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1277	004	0	1	02	01	H1277_004_0	10			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1277	004	0	1	02	01	H1277_004_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1277	004	0	1	02	01	H1277_004_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1277	004	0	1	02	01	H1277_004_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1277	004	0	1	02	01	H1277_004_0	10			Select Care Drugs	4	11	1	2	6	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1278	001	0	1	04	01	H1278_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	001	0	1	04	01	H1278_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	001	0	1	04	01	H1278_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	001	0	1	04	01	H1278_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	001	0	1	04	01	H1278_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	001	0	1	04	01	H1278_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	001	0	1	04	01	H1278_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				492.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	003	0	1	04	01	H1278_003_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	003	0	1	04	01	H1278_003_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	003	0	1	04	01	H1278_003_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	003	0	1	04	01	H1278_003_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	003	0	1	04	01	H1278_003_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	003	0	1	04	01	H1278_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	003	0	1	04	01	H1278_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				448.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	004	0	1	04	01	H1278_004_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	004	0	1	04	01	H1278_004_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	004	0	1	04	01	H1278_004_0	7			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	004	0	1	04	01	H1278_004_0	7			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	004	0	1	04	01	H1278_004_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H1278	004	0	1	04	01	H1278_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H1278	004	0	1	04	01	H1278_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											571.00	33						529.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	005	0	1	04	01	H1278_005_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	005	0	1	04	01	H1278_005_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	005	0	1	04	01	H1278_005_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	005	0	1	04	01	H1278_005_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	005	0	1	04	01	H1278_005_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	005	0	1	04	01	H1278_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	005	0	1	04	01	H1278_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				252.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	007	0	1	04	01	H1278_007_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	007	0	1	04	01	H1278_007_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	007	0	1	04	01	H1278_007_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	007	0	1	04	01	H1278_007_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	007	0	1	04	01	H1278_007_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	007	0	1	04	01	H1278_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	007	0	1	04	01	H1278_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				420.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	009	0	1	04	01	H1278_009_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	009	0	1	04	01	H1278_009_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	009	0	1	04	01	H1278_009_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	009	0	1	04	01	H1278_009_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	009	0	1	04	01	H1278_009_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	009	0	1	04	01	H1278_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	009	0	1	04	01	H1278_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				624.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	010	0	1	04	01	H1278_010_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	010	0	1	04	01	H1278_010_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	010	0	1	04	01	H1278_010_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	010	0	1	04	01	H1278_010_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	010	0	1	04	01	H1278_010_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	010	0	1	04	01	H1278_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	010	0	1	04	01	H1278_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				405.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	013	0	1	04	01	H1278_013_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	013	0	1	04	01	H1278_013_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	013	0	1	04	01	H1278_013_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	013	0	1	04	01	H1278_013_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	013	0	1	04	01	H1278_013_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	013	0	1	04	01	H1278_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	013	0	1	04	01	H1278_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				276.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	014	0	1	04	01	H1278_014_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	014	0	1	04	01	H1278_014_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	014	0	1	04	01	H1278_014_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	014	0	1	04	01	H1278_014_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	014	0	1	04	01	H1278_014_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	014	0	1	04	01	H1278_014_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	014	0	1	04	01	H1278_014_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				353.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	015	0	1	04	01	H1278_015_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	015	0	1	04	01	H1278_015_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	015	0	1	04	01	H1278_015_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	015	0	1	04	01	H1278_015_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	015	0	1	04	01	H1278_015_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	015	0	1	04	01	H1278_015_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	015	0	1	04	01	H1278_015_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				425.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	016	0	1	04	01	H1278_016_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	016	0	1	04	01	H1278_016_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	016	0	1	04	01	H1278_016_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	016	0	1	04	01	H1278_016_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	016	0	1	04	01	H1278_016_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	016	0	1	04	01	H1278_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	016	0	1	04	01	H1278_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				309.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	020	0	1	04	01	H1278_020_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	020	0	1	04	01	H1278_020_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	020	0	1	04	01	H1278_020_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	020	0	1	04	01	H1278_020_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	020	0	1	04	01	H1278_020_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	020	0	1	04	01	H1278_020_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	020	0	1	04	01	H1278_020_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				419.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	021	0	1	04	01	H1278_021_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	021	0	1	04	01	H1278_021_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	021	0	1	04	01	H1278_021_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	021	0	1	04	01	H1278_021_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	021	0	1	04	01	H1278_021_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	021	0	1	04	01	H1278_021_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	021	0	1	04	01	H1278_021_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				333.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	022	0	1	04	01	H1278_022_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	022	0	1	04	01	H1278_022_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	022	0	1	04	01	H1278_022_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	022	0	1	04	01	H1278_022_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	022	0	1	04	01	H1278_022_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	022	0	1	04	01	H1278_022_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	022	0	1	04	01	H1278_022_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				234.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	023	0	1	04	01	H1278_023_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	023	0	1	04	01	H1278_023_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	023	0	1	04	01	H1278_023_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	023	0	1	04	01	H1278_023_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	023	0	1	04	01	H1278_023_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	023	0	1	04	01	H1278_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	023	0	1	04	01	H1278_023_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				533.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	024	0	1	04	01	H1278_024_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	024	0	1	04	01	H1278_024_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	024	0	1	04	01	H1278_024_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	024	0	1	04	01	H1278_024_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1278	024	0	1	04	01	H1278_024_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	024	0	1	04	01	H1278_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	024	0	1	04	01	H1278_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				211.00	26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	028	0	1	04	01	H1278_028_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	028	0	1	04	01	H1278_028_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	028	0	1	04	01	H1278_028_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	028	0	1	04	01	H1278_028_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	028	0	1	04	01	H1278_028_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	028	0	1	04	01	H1278_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	028	0	1	04	01	H1278_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				450.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	029	0	1	04	01	H1278_029_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	029	0	1	04	01	H1278_029_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	029	0	1	04	01	H1278_029_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	029	0	1	04	01	H1278_029_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	029	0	1	04	01	H1278_029_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	029	0	1	04	01	H1278_029_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	029	0	1	04	01	H1278_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				557.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	030	0	1	04	01	H1278_030_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	030	0	1	04	01	H1278_030_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	030	0	1	04	01	H1278_030_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	030	0	1	04	01	H1278_030_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	030	0	1	04	01	H1278_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	030	0	1	04	01	H1278_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	030	0	1	04	01	H1278_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				462.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	032	0	1	04	01	H1278_032_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	032	0	1	04	01	H1278_032_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1278	032	0	1	04	01	H1278_032_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1278	032	0	1	04	01	H1278_032_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1278	032	0	1	04	01	H1278_032_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	032	0	1	04	01	H1278_032_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1278	032	0	1	04	01	H1278_032_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				491.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	001	0	1	01	01	H1280_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	001	0	1	01	01	H1280_001_0	5			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		15.00																			5.00		5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	001	0	1	01	01	H1280_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	47.00		141.00																			47.00		47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		35.00				35.00		35.00
H1280	001	0	1	01	01	H1280_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	001	0	1	01	01	H1280_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	002	0	1	01	01	H1280_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	002	0	1	01	01	H1280_002_0	5			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		15.00																			5.00		5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	002	0	1	01	01	H1280_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	47.00		141.00																			47.00		47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		35.00				35.00		35.00
H1280	002	0	1	01	01	H1280_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1280	002	0	1	01	01	H1280_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1290	001	0	1	01	01	H1290_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	001	0	1	01	01	H1290_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	001	0	1	01	01	H1290_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	001	0	1	01	01	H1290_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	001	0	1	01	01	H1290_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	001	0	1	01	01	H1290_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	001	0	1	01	01	H1290_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	002	0	1	01	01	H1290_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	002	0	1	01	01	H1290_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	002	0	1	01	01	H1290_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	002	0	1	01	01	H1290_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	002	0	1	01	01	H1290_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	002	0	1	01	01	H1290_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	002	0	1	01	01	H1290_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	003	0	1	01	01	H1290_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	003	0	1	01	01	H1290_003_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	003	0	1	01	01	H1290_003_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	003	0	1	01	01	H1290_003_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	003	0	1	01	01	H1290_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	003	0	1	01	01	H1290_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	003	0	1	01	01	H1290_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	005	0	1	01	01	H1290_005_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	005	0	1	01	01	H1290_005_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	005	0	1	01	01	H1290_005_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	005	0	1	01	01	H1290_005_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	005	0	1	01	01	H1290_005_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	005	0	1	01	01	H1290_005_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	005	0	1	01	01	H1290_005_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	013	0	1	01	01	H1290_013_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	013	0	1	01	01	H1290_013_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	013	0	1	01	01	H1290_013_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H1290	013	0	1	01	01	H1290_013_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	013	0	1	01	01	H1290_013_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	013	0	1	01	01	H1290_013_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	013	0	1	01	01	H1290_013_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	014	0	1	01	01	H1290_014_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	014	0	1	01	01	H1290_014_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	014	0	1	01	01	H1290_014_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H1290	014	0	1	01	01	H1290_014_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	014	0	1	01	01	H1290_014_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	014	0	1	01	01	H1290_014_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	014	0	1	01	01	H1290_014_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	015	0	1	01	01	H1290_015_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	015	0	1	01	01	H1290_015_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	015	0	1	01	01	H1290_015_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H1290	015	0	1	01	01	H1290_015_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	015	0	1	01	01	H1290_015_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	015	0	1	01	01	H1290_015_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	015	0	1	01	01	H1290_015_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	018	0	1	01	01	H1290_018_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	018	0	1	01	01	H1290_018_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	018	0	1	01	01	H1290_018_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H1290	018	0	1	01	01	H1290_018_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	018	0	1	01	01	H1290_018_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	018	0	1	01	01	H1290_018_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	018	0	1	01	01	H1290_018_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	019	0	1	01	01	H1290_019_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	019	0	1	01	01	H1290_019_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	019	0	1	01	01	H1290_019_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	019	0	1	01	01	H1290_019_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	019	0	1	01	01	H1290_019_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	019	0	1	01	01	H1290_019_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	019	0	1	01	01	H1290_019_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	020	0	1	01	01	H1290_020_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	020	0	1	01	01	H1290_020_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	020	0	1	01	01	H1290_020_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	020	0	1	01	01	H1290_020_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	020	0	1	01	01	H1290_020_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	020	0	1	01	01	H1290_020_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	020	0	1	01	01	H1290_020_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	021	0	1	01	01	H1290_021_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	021	0	1	01	01	H1290_021_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	021	0	1	01	01	H1290_021_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	021	0	1	01	01	H1290_021_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	021	0	1	01	01	H1290_021_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	021	0	1	01	01	H1290_021_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	021	0	1	01	01	H1290_021_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	022	0	1	01	01	H1290_022_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	022	0	1	01	01	H1290_022_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	022	0	1	01	01	H1290_022_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	022	0	1	01	01	H1290_022_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	022	0	1	01	01	H1290_022_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	022	0	1	01	01	H1290_022_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	022	0	1	01	01	H1290_022_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	023	0	1	01	01	H1290_023_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	023	0	1	01	01	H1290_023_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	023	0	1	01	01	H1290_023_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	023	0	1	01	01	H1290_023_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	023	0	1	01	01	H1290_023_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	023	0	1	01	01	H1290_023_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	023	0	1	01	01	H1290_023_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	024	0	1	01	01	H1290_024_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	024	0	1	01	01	H1290_024_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	024	0	1	01	01	H1290_024_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	024	0	1	01	01	H1290_024_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	024	0	1	01	01	H1290_024_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	024	0	1	01	01	H1290_024_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	024	0	1	01	01	H1290_024_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	025	0	1	01	01	H1290_025_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	025	0	1	01	01	H1290_025_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	025	0	1	01	01	H1290_025_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	025	0	1	01	01	H1290_025_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	025	0	1	01	01	H1290_025_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	025	0	1	01	01	H1290_025_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	025	0	1	01	01	H1290_025_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	027	0	1	01	01	H1290_027_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	027	0	1	01	01	H1290_027_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	027	0	1	01	01	H1290_027_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	027	0	1	01	01	H1290_027_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	027	0	1	01	01	H1290_027_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	027	0	1	01	01	H1290_027_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	027	0	1	01	01	H1290_027_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	029	0	1	01	01	H1290_029_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	029	0	1	01	01	H1290_029_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	029	0	1	01	01	H1290_029_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	029	0	1	01	01	H1290_029_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	029	0	1	01	01	H1290_029_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	029	0	1	01	01	H1290_029_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	029	0	1	01	01	H1290_029_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	031	0	1	01	01	H1290_031_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	031	0	1	01	01	H1290_031_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	031	0	1	01	01	H1290_031_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H1290	031	0	1	01	01	H1290_031_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	031	0	1	01	01	H1290_031_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	031	0	1	01	01	H1290_031_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	031	0	1	01	01	H1290_031_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	032	0	1	01	01	H1290_032_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	032	0	1	01	01	H1290_032_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	032	0	1	01	01	H1290_032_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H1290	032	0	1	01	01	H1290_032_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	032	0	1	01	01	H1290_032_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	032	0	1	01	01	H1290_032_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	032	0	1	01	01	H1290_032_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	033	0	1	01	01	H1290_033_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	033	0	1	01	01	H1290_033_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	033	0	1	01	01	H1290_033_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	033	0	1	01	01	H1290_033_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	033	0	1	01	01	H1290_033_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	033	0	1	01	01	H1290_033_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	033	0	1	01	01	H1290_033_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	034	0	1	01	01	H1290_034_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	034	0	1	01	01	H1290_034_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	034	0	1	01	01	H1290_034_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	034	0	1	01	01	H1290_034_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	034	0	1	01	01	H1290_034_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	034	0	1	01	01	H1290_034_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	034	0	1	01	01	H1290_034_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	035	0	1	01	01	H1290_035_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	035	0	1	01	01	H1290_035_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	035	0	1	01	01	H1290_035_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H1290	035	0	1	01	01	H1290_035_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	035	0	1	01	01	H1290_035_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	035	0	1	01	01	H1290_035_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H1290	035	0	1	01	01	H1290_035_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H1290	036	1	1	01	01	H1290_036_1	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	036	1	1	01	01	H1290_036_1	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	036	1	1	01	01	H1290_036_1	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	036	1	1	01	01	H1290_036_1	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	036	1	1	01	01	H1290_036_1	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	20.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00				8.00	16.00	20.00				8.00		8.00
H1290	036	1	1	01	01	H1290_036_1	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	036	1	1	01	01	H1290_036_1	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				0.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	036	2	1	01	01	H1290_036_2	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	036	2	1	01	01	H1290_036_2	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	036	2	1	01	01	H1290_036_2	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	036	2	1	01	01	H1290_036_2	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	036	2	1	01	01	H1290_036_2	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	20.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00				8.00	16.00	20.00				8.00		8.00
H1290	036	2	1	01	01	H1290_036_2	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	036	2	1	01	01	H1290_036_2	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				0.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	037	1	1	01	01	H1290_037_1	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	1	1	01	01	H1290_037_1	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	037	1	1	01	01	H1290_037_1	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	1	1	01	01	H1290_037_1	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	037	1	1	01	01	H1290_037_1	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	1	1	01	01	H1290_037_1	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	1	1	01	01	H1290_037_1	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	037	2	1	01	01	H1290_037_2	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	2	1	01	01	H1290_037_2	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	037	2	1	01	01	H1290_037_2	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	2	1	01	01	H1290_037_2	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	037	2	1	01	01	H1290_037_2	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	2	1	01	01	H1290_037_2	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	2	1	01	01	H1290_037_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	037	3	1	01	01	H1290_037_3	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	3	1	01	01	H1290_037_3	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	037	3	1	01	01	H1290_037_3	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	3	1	01	01	H1290_037_3	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	037	3	1	01	01	H1290_037_3	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	3	1	01	01	H1290_037_3	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	3	1	01	01	H1290_037_3	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	037	4	1	01	01	H1290_037_4	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	4	1	01	01	H1290_037_4	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	037	4	1	01	01	H1290_037_4	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	4	1	01	01	H1290_037_4	9			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	037	4	1	01	01	H1290_037_4	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	4	1	01	01	H1290_037_4	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	4	1	01	01	H1290_037_4	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	037	5	1	01	01	H1290_037_5	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	5	1	01	01	H1290_037_5	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	037	5	1	01	01	H1290_037_5	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	037	5	1	01	01	H1290_037_5	9			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	037	5	1	01	01	H1290_037_5	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	5	1	01	01	H1290_037_5	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	037	5	1	01	01	H1290_037_5	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	039	0	1	01	01	H1290_039_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	039	0	1	01	01	H1290_039_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	039	0	1	01	01	H1290_039_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	039	0	1	01	01	H1290_039_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	039	0	1	01	01	H1290_039_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	039	0	1	01	01	H1290_039_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	039	0	1	01	01	H1290_039_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	041	0	1	01	01	H1290_041_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	041	0	1	01	01	H1290_041_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	041	0	1	01	01	H1290_041_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	041	0	1	01	01	H1290_041_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	041	0	1	01	01	H1290_041_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	041	0	1	01	01	H1290_041_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	041	0	1	01	01	H1290_041_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1290	044	1	1	01	01	H1290_044_1	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	044	1	1	01	01	H1290_044_1	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	044	1	1	01	01	H1290_044_1	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	044	1	1	01	01	H1290_044_1	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	044	1	1	01	01	H1290_044_1	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	044	1	1	01	01	H1290_044_1	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	044	1	1	01	01	H1290_044_1	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	044	2	1	01	01	H1290_044_2	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	044	2	1	01	01	H1290_044_2	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	044	2	1	01	01	H1290_044_2	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	044	2	1	01	01	H1290_044_2	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	044	2	1	01	01	H1290_044_2	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	044	2	1	01	01	H1290_044_2	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	044	2	1	01	01	H1290_044_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	044	3	1	01	01	H1290_044_3	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	044	3	1	01	01	H1290_044_3	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	044	3	1	01	01	H1290_044_3	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	044	3	1	01	01	H1290_044_3	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	044	3	1	01	01	H1290_044_3	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	044	3	1	01	01	H1290_044_3	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	044	3	1	01	01	H1290_044_3	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	045	0	1	01	01	H1290_045_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	045	0	1	01	01	H1290_045_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	045	0	1	01	01	H1290_045_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	045	0	1	01	01	H1290_045_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	045	0	1	01	01	H1290_045_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	045	0	1	01	01	H1290_045_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	045	0	1	01	01	H1290_045_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	046	0	1	01	01	H1290_046_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	046	0	1	01	01	H1290_046_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	046	0	1	01	01	H1290_046_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	046	0	1	01	01	H1290_046_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	046	0	1	01	01	H1290_046_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	046	0	1	01	01	H1290_046_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	046	0	1	01	01	H1290_046_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	049	0	1	01	01	H1290_049_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	049	0	1	01	01	H1290_049_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	049	0	1	01	01	H1290_049_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H1290	049	0	1	01	01	H1290_049_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	049	0	1	01	01	H1290_049_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	049	0	1	01	01	H1290_049_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	049	0	1	01	01	H1290_049_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	050	0	1	01	01	H1290_050_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	050	0	1	01	01	H1290_050_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	050	0	1	01	01	H1290_050_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	050	0	1	01	01	H1290_050_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H1290	050	0	1	01	01	H1290_050_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	050	0	1	01	01	H1290_050_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	050	0	1	01	01	H1290_050_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	051	1	1	01	01	H1290_051_1	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	051	1	1	01	01	H1290_051_1	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	051	1	1	01	01	H1290_051_1	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H1290	051	1	1	01	01	H1290_051_1	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	051	1	1	01	01	H1290_051_1	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	051	1	1	01	01	H1290_051_1	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	051	1	1	01	01	H1290_051_1	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	051	2	1	01	01	H1290_051_2	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1290	051	2	1	01	01	H1290_051_2	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1290	051	2	1	01	01	H1290_051_2	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H1290	051	2	1	01	01	H1290_051_2	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H1290	051	2	1	01	01	H1290_051_2	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	051	2	1	01	01	H1290_051_2	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	051	2	1	01	01	H1290_051_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1290	052	0	1	01	01	H1290_052_0	13		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00
H1290	052	0	1	01	01	H1290_052_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	052	0	1	01	01	H1290_052_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	052	0	1	01	01	H1290_052_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1290	052	0	1	01	01	H1290_052_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00						35.00						35.00		35.00
H1290	052	0	1	01	01	H1290_052_0	13		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1290	052	0	1	01	01	H1290_052_0	13		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1304	004	0	1	04	01	H1304_004_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1304	004	0	1	04	01	H1304_004_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H1304	004	0	1	04	01	H1304_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H1304	004	0	1	04	01	H1304_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	004	0	1	04	01	H1304_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1304	011	1	1	04	01	H1304_011_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1304	011	1	1	04	01	H1304_011_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H1304	011	1	1	04	01	H1304_011_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	011	1	1	04	01	H1304_011_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	011	1	1	04	01	H1304_011_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1038.20	28						1038.20	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1304	011	2	1	04	01	H1304_011_2	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1304	011	2	1	04	01	H1304_011_2	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H1304	011	2	1	04	01	H1304_011_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	011	2	1	04	01	H1304_011_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	011	2	1	04	01	H1304_011_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1038.20	28						1038.20	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1304	012	1	1	04	01	H1304_012_1	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1304	012	1	1	04	01	H1304_012_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H1304	012	1	1	04	01	H1304_012_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H1304	012	1	1	04	01	H1304_012_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	012	1	1	04	01	H1304_012_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1304	012	2	1	04	01	H1304_012_2	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1304	012	2	1	04	01	H1304_012_2	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H1304	012	2	1	04	01	H1304_012_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H1304	012	2	1	04	01	H1304_012_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1304	012	2	1	04	01	H1304_012_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1339	001	0	1	01	01	H1339_001_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1339	001	0	1	01	01	H1339_001_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	15.00	20.00																			10.00	15.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	15.00	20.00				10.00	15.00	20.00				10.00		10.00
H1339	001	0	1	01	01	H1339_001_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	70.50	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H1339	001	0	1	01	01	H1339_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	150.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H1339	001	0	1	01	01	H1339_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1347	001	0	1	04	01	H1347_001_0	3			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		20.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		20.00	0.00		0.00	10.00		10.00
H1347	001	0	1	04	01	H1347_001_0	3			Preferred Generic	4	01	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		20.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H1347	001	0	1	04	01	H1347_001_0	3			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								20.00		60.00					13.00		26.00											20.00		40.00				13.00		26.00				20.00				20.00			0.66	0.43		0.66	0.43	0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	13.00		26.00	20.00		40.00	13.00		26.00	20.00		20.00
H1347	001	0	1	04	01	H1347_001_0	3			Generic	4	01	1	2	2	3		110	01		110	1				30		90	1	2				30		90	30		31								20.00		60.00					13.00		26.00											20.00		40.00				13.00		26.00				20.00				20.00			0.66	0.43		0.66	0.43	0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H1347	001	0	1	04	01	H1347_001_0	3			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H1347	001	0	1	04	01	H1347_001_0	3			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1347	001	0	1	04	01	H1347_001_0	3			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		300.00					93.00		186.00											100.00		200.00				93.00		186.00				100.00				100.00			3.33	3.10		3.33	3.10	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H1347	001	0	1	04	01	H1347_001_0	3			Non-Preferred Drug	4	11	1	2	4	3		110	01		110	1				30		90	1	2				30		90	30		31								100.00		300.00					93.00		186.00											100.00		200.00				93.00		186.00				100.00				100.00			3.33	3.10		3.33	3.10	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1347	001	0	1	04	01	H1347_001_0	3			Specialty Tier	4	10	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1347	002	0	1	04	01	H1347_002_0	3			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					0.00		0.00											5.00		10.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00	0.00		0.00	5.00		10.00	0.00		0.00	5.00		5.00
H1347	002	0	1	04	01	H1347_002_0	3			Preferred Generic	4	01	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					0.00		0.00											5.00		10.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H1347	002	0	1	04	01	H1347_002_0	3			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		45.00					5.00		10.00											15.00		30.00				0.00		0.00				15.00				15.00			0.50	0.16		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00	5.00		10.00	15.00		30.00	0.00		0.00	15.00		15.00
H1347	002	0	1	04	01	H1347_002_0	3			Generic	4	01	1	2	2	3		110	01		110	1				30		90	1	2				30		90	30		31								15.00		45.00					5.00		10.00											15.00		30.00				0.00		0.00				15.00				15.00			0.50	0.16		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H1347	002	0	1	04	01	H1347_002_0	3			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H1347	002	0	1	04	01	H1347_002_0	3			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1347	002	0	1	04	01	H1347_002_0	3			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		300.00					93.00		186.00											100.00		200.00				93.00		186.00				100.00				100.00			3.33	3.10		3.33	3.10	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H1347	002	0	1	04	01	H1347_002_0	3			Non-Preferred Drug	4	11	1	2	4	3		110	01		110	1				30		90	1	2				30		90	30		31								100.00		300.00					93.00		186.00											100.00		200.00				93.00		186.00				100.00				100.00			3.33	3.10		3.33	3.10	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1347	002	0	1	04	01	H1347_002_0	3			Specialty Tier	4	10	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1347	003	0	1	04	01	H1347_003_0	3			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					0.00		0.00											5.00		10.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00	0.00		0.00	5.00		10.00	0.00		0.00	5.00		5.00
H1347	003	0	1	04	01	H1347_003_0	3			Preferred Generic	4	01	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					0.00		0.00											5.00		10.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H1347	003	0	1	04	01	H1347_003_0	3			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		45.00					5.00		10.00											15.00		30.00				0.00		0.00				15.00				15.00			0.50	0.16		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00	5.00		10.00	15.00		30.00	0.00		0.00	15.00		15.00
H1347	003	0	1	04	01	H1347_003_0	3			Generic	4	01	1	2	2	3		110	01		110	1				30		90	1	2				30		90	30		31								15.00		45.00					5.00		10.00											15.00		30.00				0.00		0.00				15.00				15.00			0.50	0.16		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H1347	003	0	1	04	01	H1347_003_0	3			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H1347	003	0	1	04	01	H1347_003_0	3			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1347	003	0	1	04	01	H1347_003_0	3			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		300.00					93.00		186.00											100.00		200.00				93.00		186.00				100.00				100.00			3.33	3.10		3.33	3.10	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
H1347	003	0	1	04	01	H1347_003_0	3			Non-Preferred Drug	4	11	1	2	4	3		110	01		110	1				30		90	1	2				30		90	30		31								100.00		300.00					93.00		186.00											100.00		200.00				93.00		186.00				100.00				100.00			3.33	3.10		3.33	3.10	3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H1347	003	0	1	04	01	H1347_003_0	3			Specialty Tier	4	10	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1350	023	1	1	01	01	H1350_023_1	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	023	1	1	01	01	H1350_023_1	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	12.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													6.00	12.00	18.00				6.00	12.00	12.00				6.00		6.00
H1350	023	1	1	01	01	H1350_023_1	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	023	1	1	01	01	H1350_023_1	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	023	1	1	01	01	H1350_023_1	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	023	1	1	01	01	H1350_023_1	5			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	023	2	1	01	01	H1350_023_2	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	023	2	1	01	01	H1350_023_2	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	12.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													6.00	12.00	18.00				6.00	12.00	12.00				6.00		6.00
H1350	023	2	1	01	01	H1350_023_2	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	023	2	1	01	01	H1350_023_2	4			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	023	2	1	01	01	H1350_023_2	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	023	2	1	01	01	H1350_023_2	4			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	1	1	01	01	H1350_024_1	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	1	1	01	01	H1350_024_1	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H1350	024	1	1	01	01	H1350_024_1	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	024	1	1	01	01	H1350_024_1	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	024	1	1	01	01	H1350_024_1	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	1	1	01	01	H1350_024_1	5			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	2	1	01	01	H1350_024_2	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	2	1	01	01	H1350_024_2	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H1350	024	2	1	01	01	H1350_024_2	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	024	2	1	01	01	H1350_024_2	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	024	2	1	01	01	H1350_024_2	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	2	1	01	01	H1350_024_2	5			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	3	1	01	01	H1350_024_3	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	3	1	01	01	H1350_024_3	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H1350	024	3	1	01	01	H1350_024_3	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	024	3	1	01	01	H1350_024_3	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	024	3	1	01	01	H1350_024_3	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	024	3	1	01	01	H1350_024_3	5			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	026	0	1	01	01	H1350_026_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	026	0	1	01	01	H1350_026_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1350	026	0	1	01	01	H1350_026_0	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	026	0	1	01	01	H1350_026_0	4			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	026	0	1	01	01	H1350_026_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	026	0	1	01	01	H1350_026_0	4			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	028	0	1	01	01	H1350_028_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	028	0	1	01	01	H1350_028_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	028	0	1	01	01	H1350_028_0	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	028	0	1	01	01	H1350_028_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	028	0	1	01	01	H1350_028_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	028	0	1	01	01	H1350_028_0	4			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	029	0	1	01	01	H1350_029_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	029	0	1	01	01	H1350_029_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	029	0	1	01	01	H1350_029_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	029	0	1	01	01	H1350_029_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	029	0	1	01	01	H1350_029_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	029	0	1	01	01	H1350_029_0	5			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1350	030	0	1	01	01	H1350_030_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	030	0	1	01	01	H1350_030_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1350	030	0	1	01	01	H1350_030_0	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	030	0	1	01	01	H1350_030_0	4			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	030	0	1	01	01	H1350_030_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	030	0	1	01	01	H1350_030_0	4			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	1	1	01	01	H1350_031_1	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	1	1	01	01	H1350_031_1	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H1350	031	1	1	01	01	H1350_031_1	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	031	1	1	01	01	H1350_031_1	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	031	1	1	01	01	H1350_031_1	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	1	1	01	01	H1350_031_1	5			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	2	1	01	01	H1350_031_2	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	2	1	01	01	H1350_031_2	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H1350	031	2	1	01	01	H1350_031_2	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	031	2	1	01	01	H1350_031_2	4			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	031	2	1	01	01	H1350_031_2	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	2	1	01	01	H1350_031_2	4			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	3	1	01	01	H1350_031_3	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	3	1	01	01	H1350_031_3	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H1350	031	3	1	01	01	H1350_031_3	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	031	3	1	01	01	H1350_031_3	4			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	97.00	194.00	291.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1350	031	3	1	01	01	H1350_031_3	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				990.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1350	031	3	1	01	01	H1350_031_3	4			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H1352	004	0	1	01	01	H1352_004_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1352	004	0	1	01	01	H1352_004_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1352	004	0	1	01	01	H1352_004_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1352	004	0	1	01	01	H1352_004_0	6			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1352	004	0	1	01	01	H1352_004_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1352	004	0	1	01	01	H1352_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1352	004	0	1	01	01	H1352_004_0	6			Specialty Tier	4	11	1	3	5	1	010		01	010		1	30								30						30		31	100.00			1320.00	33																	100.00			33															100.00		33		100.00	33	3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1353	005	0	1	01	01	H1353_005_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	005	0	1	01	01	H1353_005_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	005	0	1	01	01	H1353_005_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1353	005	0	1	01	01	H1353_005_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.01	50	50	50				89.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1353	005	0	1	01	01	H1353_005_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1353	005	0	1	01	01	H1353_005_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	006	0	1	01	01	H1353_006_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	006	0	1	01	01	H1353_006_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	006	0	1	01	01	H1353_006_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1353	006	0	1	01	01	H1353_006_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.17	50	50	50				83.17	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1353	006	0	1	01	01	H1353_006_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1353	006	0	1	01	01	H1353_006_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	007	0	1	01	01	H1353_007_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	007	0	1	01	01	H1353_007_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1353	007	0	1	01	01	H1353_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1353	007	0	1	01	01	H1353_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.73	44	44	44				98.73	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1353	007	0	1	01	01	H1353_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1353	007	0	1	01	01	H1353_007_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	001	0	1	04	01	H1365_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	001	0	1	04	01	H1365_001_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	001	0	1	04	01	H1365_001_0	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1365	001	0	1	04	01	H1365_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	001	0	1	04	01	H1365_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	29						600.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H1365	001	0	1	04	01	H1365_001_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	001	0	1	04	01	H1365_001_0	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.17	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1365	004	2	1	04	01	H1365_004_2	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	2	1	04	01	H1365_004_2	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	2	1	04	01	H1365_004_2	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1365	004	2	1	04	01	H1365_004_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	2	1	04	01	H1365_004_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	29						600.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H1365	004	2	1	04	01	H1365_004_2	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	2	1	04	01	H1365_004_2	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.16	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1365	004	3	1	04	01	H1365_004_3	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	3	1	04	01	H1365_004_3	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	3	1	04	01	H1365_004_3	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1365	004	3	1	04	01	H1365_004_3	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	3	1	04	01	H1365_004_3	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	29						600.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H1365	004	3	1	04	01	H1365_004_3	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1365	004	3	1	04	01	H1365_004_3	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.16	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1372	002	0	1	01	01	H1372_002_0	7			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	002	0	1	01	01	H1372_002_0	7			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	002	0	1	01	01	H1372_002_0	7			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1372	002	0	1	01	01	H1372_002_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	002	0	1	01	01	H1372_002_0	7			Specialty Tier	4	01	1	1	5	1	010		10	010		1	30								30							10	31					28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	003	0	1	01	01	H1372_003_0	7			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	003	0	1	01	01	H1372_003_0	7			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	003	0	1	01	01	H1372_003_0	7			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1372	003	0	1	01	01	H1372_003_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1372	003	0	1	01	01	H1372_003_0	7			Specialty Tier	4	01	1	1	5	1	010		10	010		1	30								30							10	31					28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1395	002	0	1	04	01	H1395_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1395	002	0	1	04	01	H1395_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1395	002	0	1	04	01	H1395_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1395	002	0	1	04	01	H1395_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											70.60	50	50	50				70.60	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1395	002	0	1	04	01	H1395_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1395	002	0	1	04	01	H1395_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1395	003	0	1	04	01	H1395_003_0	17			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1395	003	0	1	04	01	H1395_003_0	17			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1395	003	0	1	04	01	H1395_003_0	17			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1395	003	0	1	04	01	H1395_003_0	17			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.28	48	48	48				99.28	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1395	003	0	1	04	01	H1395_003_0	17			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1395	003	0	1	04	01	H1395_003_0	17			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	009	0	1	02	01	H1416_009_0	9			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	009	0	1	02	01	H1416_009_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	009	0	1	02	01	H1416_009_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	009	0	1	02	01	H1416_009_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.54	45	45	45				98.54	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	009	0	1	02	01	H1416_009_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	009	0	1	02	01	H1416_009_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	023	0	1	01	01	H1416_023_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	023	0	1	01	01	H1416_023_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	023	0	1	01	01	H1416_023_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1416	023	0	1	01	01	H1416_023_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.82	45	45	45				99.82	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	023	0	1	01	01	H1416_023_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	023	0	1	01	01	H1416_023_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	026	0	1	02	01	H1416_026_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	026	0	1	02	01	H1416_026_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	026	0	1	02	01	H1416_026_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	026	0	1	02	01	H1416_026_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.15	50	50	50				92.15	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	026	0	1	02	01	H1416_026_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	026	0	1	02	01	H1416_026_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	041	0	1	01	01	H1416_041_0	9			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	041	0	1	01	01	H1416_041_0	9			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	041	0	1	01	01	H1416_041_0	9			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1416	041	0	1	01	01	H1416_041_0	9			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.96	50	50	50				82.96	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	041	0	1	01	01	H1416_041_0	9			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	041	0	1	01	01	H1416_041_0	9			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	042	0	1	01	01	H1416_042_0	8			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	042	0	1	01	01	H1416_042_0	8			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	042	0	1	01	01	H1416_042_0	8			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1416	042	0	1	01	01	H1416_042_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.60	48	48	48				99.60	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	042	0	1	01	01	H1416_042_0	8			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	042	0	1	01	01	H1416_042_0	8			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	055	0	1	01	01	H1416_055_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	055	0	1	01	01	H1416_055_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	0.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	055	0	1	01	01	H1416_055_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	055	0	1	01	01	H1416_055_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											73.22	50	50	50				73.22	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	055	0	1	01	01	H1416_055_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	055	0	1	01	01	H1416_055_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	056	0	1	01	01	H1416_056_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	056	0	1	01	01	H1416_056_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	056	0	1	01	01	H1416_056_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	056	0	1	01	01	H1416_056_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.59	50	50	50				82.59	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	056	0	1	01	01	H1416_056_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	056	0	1	01	01	H1416_056_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	057	0	1	01	01	H1416_057_0	22			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	057	0	1	01	01	H1416_057_0	22			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	057	0	1	01	01	H1416_057_0	22			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	057	0	1	01	01	H1416_057_0	22			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											95.33	50	50	50				95.33	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	057	0	1	01	01	H1416_057_0	22			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	057	0	1	01	01	H1416_057_0	22			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	064	0	1	01	01	H1416_064_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	064	0	1	01	01	H1416_064_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	064	0	1	01	01	H1416_064_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	064	0	1	01	01	H1416_064_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											62.78	50	50	50				62.78	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	064	0	1	01	01	H1416_064_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	064	0	1	01	01	H1416_064_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	065	0	1	01	01	H1416_065_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	065	0	1	01	01	H1416_065_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	065	0	1	01	01	H1416_065_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	065	0	1	01	01	H1416_065_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											75.92	50	50	50				75.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	065	0	1	01	01	H1416_065_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	065	0	1	01	01	H1416_065_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	068	0	1	01	01	H1416_068_0	9			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	068	0	1	01	01	H1416_068_0	9			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	068	0	1	01	01	H1416_068_0	9			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1416	068	0	1	01	01	H1416_068_0	9			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.64	46	46	46				99.64	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	068	0	1	01	01	H1416_068_0	9			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	068	0	1	01	01	H1416_068_0	9			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	070	0	1	01	01	H1416_070_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	070	0	1	01	01	H1416_070_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1416	070	0	1	01	01	H1416_070_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	070	0	1	01	01	H1416_070_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	070	0	1	01	01	H1416_070_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.27	50	50	50				89.27	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	070	0	1	01	01	H1416_070_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	070	0	1	01	01	H1416_070_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	070	0	1	01	01	H1416_070_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1416	071	0	1	01	01	H1416_071_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	071	0	1	01	01	H1416_071_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	071	0	1	01	01	H1416_071_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	071	0	1	01	01	H1416_071_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.70	50	50	50				82.70	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	071	0	1	01	01	H1416_071_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	071	0	1	01	01	H1416_071_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	072	0	1	01	01	H1416_072_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	072	0	1	01	01	H1416_072_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1416	072	0	1	01	01	H1416_072_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	072	0	1	01	01	H1416_072_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	072	0	1	01	01	H1416_072_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.63	50	50	50				81.63	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	072	0	1	01	01	H1416_072_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	072	0	1	01	01	H1416_072_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	072	0	1	01	01	H1416_072_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1416	077	0	1	02	01	H1416_077_0	20			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	077	0	1	02	01	H1416_077_0	20			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	077	0	1	02	01	H1416_077_0	20			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	077	0	1	02	01	H1416_077_0	20			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.70	50	50	50				86.70	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	077	0	1	02	01	H1416_077_0	20			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	077	0	1	02	01	H1416_077_0	20			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	079	0	1	01	01	H1416_079_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	079	0	1	01	01	H1416_079_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	079	0	1	01	01	H1416_079_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	079	0	1	01	01	H1416_079_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.34	50	50	50				83.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	079	0	1	01	01	H1416_079_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	079	0	1	01	01	H1416_079_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	082	0	1	02	01	H1416_082_0	9			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	082	0	1	02	01	H1416_082_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1416	082	0	1	02	01	H1416_082_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1416	082	0	1	02	01	H1416_082_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.89	50	50	50				91.89	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1416	082	0	1	02	01	H1416_082_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1416	082	0	1	02	01	H1416_082_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	001	0	1	01	01	H1423_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	001	0	1	01	01	H1423_001_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	001	0	1	01	01	H1423_001_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	001	0	1	01	01	H1423_001_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	001	0	1	01	01	H1423_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	001	0	1	01	01	H1423_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	001	0	1	01	01	H1423_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	001	0	1	01	01	H1423_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H1423	001	0	1	01	01	H1423_001_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	002	0	1	01	01	H1423_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	002	0	1	01	01	H1423_002_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	002	0	1	01	01	H1423_002_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	002	0	1	01	01	H1423_002_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	002	0	1	01	01	H1423_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	002	0	1	01	01	H1423_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	002	0	1	01	01	H1423_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	002	0	1	01	01	H1423_002_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H1423	002	0	1	01	01	H1423_002_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	004	0	1	01	01	H1423_004_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	004	0	1	01	01	H1423_004_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	004	0	1	01	01	H1423_004_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	004	0	1	01	01	H1423_004_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	004	0	1	01	01	H1423_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	004	0	1	01	01	H1423_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	004	0	1	01	01	H1423_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	004	0	1	01	01	H1423_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H1423	004	0	1	01	01	H1423_004_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	005	0	1	01	01	H1423_005_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	005	0	1	01	01	H1423_005_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.50	31.00	46.50					10.50	21.00	31.50					0.00	0.00	0.00																15.50				15.50			0.52	0.35	0.00			0.46	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	005	0	1	01	01	H1423_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	005	0	1	01	01	H1423_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					90.00	180.00	270.00					90.00	180.00	180.00																95.00				95.00			3.17	3.00	3.00			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	005	0	1	01	01	H1423_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	005	0	1	01	01	H1423_005_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H1423	005	0	1	01	01	H1423_005_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	007	0	1	01	01	H1423_007_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	007	0	1	01	01	H1423_007_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	007	0	1	01	01	H1423_007_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	007	0	1	01	01	H1423_007_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	007	0	1	01	01	H1423_007_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1423	007	0	1	01	01	H1423_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1423	007	0	1	01	01	H1423_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	007	0	1	01	01	H1423_007_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1423	007	0	1	01	01	H1423_007_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	008	0	1	01	01	H1423_008_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	008	0	1	01	01	H1423_008_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	008	0	1	01	01	H1423_008_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	008	0	1	01	01	H1423_008_0	6			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	008	0	1	01	01	H1423_008_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1423	008	0	1	01	01	H1423_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1423	008	0	1	01	01	H1423_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1423	008	0	1	01	01	H1423_008_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1423	008	0	1	01	01	H1423_008_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1423	009	0	1	01	01	H1423_009_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1423	009	0	1	01	01	H1423_009_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1423	009	0	1	01	01	H1423_009_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1423	009	0	1	01	01	H1423_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1423	009	0	1	01	01	H1423_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1423	009	0	1	01	01	H1423_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1426	001	0	1	01	01	H1426_001_0	11			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	001	0	1	01	01	H1426_001_0	11			Preferred Generic	4	01	1	2	1	3	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1426	001	0	1	01	01	H1426_001_0	11			Generic	4	01	3	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	001	0	1	01	01	H1426_001_0	11			Generic	4	01	3	2	2	3	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1426	001	0	1	01	01	H1426_001_0	11			Preferred Brand	4	10	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	30.00		60.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	001	0	1	01	01	H1426_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		200.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	001	0	1	01	01	H1426_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00						0.00						0.00		0.00
H1426	002	0	1	01	01	H1426_002_0	12			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	002	0	1	01	01	H1426_002_0	12			Preferred Generic	4	01	1	2	1	3	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1426	002	0	1	01	01	H1426_002_0	12			Generic	4	01	3	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	002	0	1	01	01	H1426_002_0	12			Generic	4	01	3	2	2	3	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1426	002	0	1	01	01	H1426_002_0	12			Preferred Brand	4	10	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	30.00		60.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	002	0	1	01	01	H1426_002_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		200.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H1426	002	0	1	01	01	H1426_002_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00						0.00						0.00		0.00
H1463	003	0	1	01	01	H1463_003_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	003	0	1	01	01	H1463_003_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1463	003	0	1	01	01	H1463_003_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1463	003	0	1	01	01	H1463_003_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1463	003	0	1	01	01	H1463_003_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				64.79	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1463	003	0	1	01	01	H1463_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	015	0	1	02	01	H1463_015_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	015	0	1	02	01	H1463_015_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1463	015	0	1	02	01	H1463_015_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1463	015	0	1	02	01	H1463_015_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1463	015	0	1	02	01	H1463_015_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				79.20	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1463	015	0	1	02	01	H1463_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	019	0	1	02	01	H1463_019_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	019	0	1	02	01	H1463_019_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1463	019	0	1	02	01	H1463_019_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1463	019	0	1	02	01	H1463_019_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1463	019	0	1	02	01	H1463_019_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				64.45	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1463	019	0	1	02	01	H1463_019_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	041	0	1	01	01	H1463_041_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	041	0	1	01	01	H1463_041_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1463	041	0	1	01	01	H1463_041_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1463	041	0	1	01	01	H1463_041_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1463	041	0	1	01	01	H1463_041_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				91.22	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1463	041	0	1	01	01	H1463_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	042	0	1	02	01	H1463_042_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	042	0	1	02	01	H1463_042_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1463	042	0	1	02	01	H1463_042_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1463	042	0	1	02	01	H1463_042_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1463	042	0	1	02	01	H1463_042_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				98.30	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1463	042	0	1	02	01	H1463_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	044	0	1	02	01	H1463_044_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1463	044	0	1	02	01	H1463_044_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1463	044	0	1	02	01	H1463_044_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1463	044	0	1	02	01	H1463_044_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1463	044	0	1	02	01	H1463_044_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.19	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1463	044	0	1	02	01	H1463_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1468	007	0	1	01	01	H1468_007_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1468	007	0	1	01	01	H1468_007_0	4			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1468	007	0	1	01	01	H1468_007_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1468	007	0	1	01	01	H1468_007_0	4			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1468	007	0	1	01	01	H1468_007_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	007	0	1	01	01	H1468_007_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	007	0	1	01	01	H1468_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1468	013	0	1	01	01	H1468_013_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1468	013	0	1	01	01	H1468_013_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1468	013	0	1	01	01	H1468_013_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1468	013	0	1	01	01	H1468_013_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1468	013	0	1	01	01	H1468_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	013	0	1	01	01	H1468_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	013	0	1	01	01	H1468_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1468	014	0	1	01	01	H1468_014_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H1468	014	0	1	01	01	H1468_014_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H1468	014	0	1	01	01	H1468_014_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	014	0	1	01	01	H1468_014_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	014	0	1	01	01	H1468_014_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1468	017	0	1	01	01	H1468_017_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1468	017	0	1	01	01	H1468_017_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1468	017	0	1	01	01	H1468_017_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1468	017	0	1	01	01	H1468_017_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1468	017	0	1	01	01	H1468_017_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	017	0	1	01	01	H1468_017_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	017	0	1	01	01	H1468_017_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1468	017	0	1	01	01	H1468_017_0	7			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1468	018	0	1	01	01	H1468_018_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1468	018	0	1	01	01	H1468_018_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1468	018	0	1	01	01	H1468_018_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1468	018	0	1	01	01	H1468_018_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1468	018	0	1	01	01	H1468_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	018	0	1	01	01	H1468_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1468	018	0	1	01	01	H1468_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1526	001	0	1	02	01	H1526_001_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	001	0	1	02	01	H1526_001_0	12			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	001	0	1	02	01	H1526_001_0	12			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	12.00				5.00	5.00	5.00				5.00		5.00
H1526	001	0	1	02	01	H1526_001_0	12			Generic	4	01	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	001	0	1	02	01	H1526_001_0	12			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	100.00				35.00	35.00	35.00				35.00		35.00
H1526	001	0	1	02	01	H1526_001_0	12			Preferred Brand	4	10	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										2																	
H1526	001	0	1	02	01	H1526_001_0	12			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	001	0	1	02	01	H1526_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1232.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	001	0	1	02	01	H1526_001_0	12			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1526	001	0	1	02	01	H1526_001_0	12			Select Diabetic Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	003	0	1	02	01	H1526_003_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	003	0	1	02	01	H1526_003_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	003	0	1	02	01	H1526_003_0	11			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	12.00				5.00	5.00	5.00				5.00		5.00
H1526	003	0	1	02	01	H1526_003_0	11			Generic	4	01	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	003	0	1	02	01	H1526_003_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	100.00				35.00	35.00	35.00				35.00		35.00
H1526	003	0	1	02	01	H1526_003_0	11			Preferred Brand	4	10	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										2																	
H1526	003	0	1	02	01	H1526_003_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	003	0	1	02	01	H1526_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1013.62	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	003	0	1	02	01	H1526_003_0	11			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1526	003	0	1	02	01	H1526_003_0	11			Select Diabetic Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	005	0	1	02	01	H1526_005_0	13			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	005	0	1	02	01	H1526_005_0	13			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	005	0	1	02	01	H1526_005_0	13			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	12.00				5.00	5.00	5.00				5.00		5.00
H1526	005	0	1	02	01	H1526_005_0	13			Generic	4	01	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1526	005	0	1	02	01	H1526_005_0	13			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	100.00				35.00	35.00	35.00				35.00		35.00
H1526	005	0	1	02	01	H1526_005_0	13			Preferred Brand	4	10	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										2																	
H1526	005	0	1	02	01	H1526_005_0	13			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	005	0	1	02	01	H1526_005_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1238.94	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H1526	005	0	1	02	01	H1526_005_0	13			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1526	005	0	1	02	01	H1526_005_0	13			Select Diabetic Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H1607	012	0	1	04	01	H1607_012_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	012	0	1	04	01	H1607_012_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								17.00	34.00	51.00					12.00	24.00	36.00					0.00	0.00	0.00																17.00				17.00			0.57	0.40	0.00			0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	012	0	1	04	01	H1607_012_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1607	012	0	1	04	01	H1607_012_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	012	0	1	04	01	H1607_012_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												32							32						32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	012	0	1	04	01	H1607_012_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	012	0	1	04	01	H1607_012_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1607	015	0	1	04	01	H1607_015_0	13			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	015	0	1	04	01	H1607_015_0	13			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1607	015	0	1	04	01	H1607_015_0	13			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	015	0	1	04	01	H1607_015_0	13			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H1607	015	0	1	04	01	H1607_015_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	015	0	1	04	01	H1607_015_0	13			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	015	0	1	04	01	H1607_015_0	13			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1607	015	0	1	04	01	H1607_015_0	13			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1608	001	0	1	04	01	H1608_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	001	0	1	04	01	H1608_001_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	001	0	1	04	01	H1608_001_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	001	0	1	04	01	H1608_001_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	001	0	1	04	01	H1608_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	001	0	1	04	01	H1608_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	001	0	1	04	01	H1608_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											685.68	33						669.15	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	012	0	1	04	01	H1608_012_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	012	0	1	04	01	H1608_012_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	012	0	1	04	01	H1608_012_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	012	0	1	04	01	H1608_012_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	012	0	1	04	01	H1608_012_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	012	0	1	04	01	H1608_012_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	012	0	1	04	01	H1608_012_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											841.10	33						618.42	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	013	0	1	04	01	H1608_013_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	013	0	1	04	01	H1608_013_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	013	0	1	04	01	H1608_013_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	013	0	1	04	01	H1608_013_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	013	0	1	04	01	H1608_013_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	013	0	1	04	01	H1608_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	013	0	1	04	01	H1608_013_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											974.46	30						700.36	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	016	0	1	04	01	H1608_016_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	016	0	1	04	01	H1608_016_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	016	0	1	04	01	H1608_016_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	016	0	1	04	01	H1608_016_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	016	0	1	04	01	H1608_016_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	016	0	1	04	01	H1608_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	016	0	1	04	01	H1608_016_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											681.09	33						631.84	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	017	0	1	04	01	H1608_017_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	017	0	1	04	01	H1608_017_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	017	0	1	04	01	H1608_017_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	017	0	1	04	01	H1608_017_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	017	0	1	04	01	H1608_017_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	017	0	1	04	01	H1608_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	017	0	1	04	01	H1608_017_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											788.65	33						676.42	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	018	0	1	04	01	H1608_018_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	018	0	1	04	01	H1608_018_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	018	0	1	04	01	H1608_018_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	018	0	1	04	01	H1608_018_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	018	0	1	04	01	H1608_018_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	018	0	1	04	01	H1608_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	018	0	1	04	01	H1608_018_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											737.21	33						664.29	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	021	0	1	04	01	H1608_021_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	021	0	1	04	01	H1608_021_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	021	0	1	04	01	H1608_021_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	021	0	1	04	01	H1608_021_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	021	0	1	04	01	H1608_021_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	021	0	1	04	01	H1608_021_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	021	0	1	04	01	H1608_021_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											744.14	33						608.61	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	024	0	1	04	01	H1608_024_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	024	0	1	04	01	H1608_024_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	024	0	1	04	01	H1608_024_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	024	0	1	04	01	H1608_024_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	024	0	1	04	01	H1608_024_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	024	0	1	04	01	H1608_024_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	024	0	1	04	01	H1608_024_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.63	33						623.23	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	026	0	1	04	01	H1608_026_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	026	0	1	04	01	H1608_026_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1608	026	0	1	04	01	H1608_026_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	026	0	1	04	01	H1608_026_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1608	026	0	1	04	01	H1608_026_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	026	0	1	04	01	H1608_026_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	026	0	1	04	01	H1608_026_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											804.48	33						562.46	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	027	0	1	04	01	H1608_027_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	027	0	1	04	01	H1608_027_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1608	027	0	1	04	01	H1608_027_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	027	0	1	04	01	H1608_027_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1608	027	0	1	04	01	H1608_027_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	027	0	1	04	01	H1608_027_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	027	0	1	04	01	H1608_027_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											990.31	33						687.61	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	028	0	1	04	01	H1608_028_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	028	0	1	04	01	H1608_028_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	028	0	1	04	01	H1608_028_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	028	0	1	04	01	H1608_028_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	028	0	1	04	01	H1608_028_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	028	0	1	04	01	H1608_028_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	028	0	1	04	01	H1608_028_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											826.39	33						641.44	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	029	0	1	04	01	H1608_029_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	029	0	1	04	01	H1608_029_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	029	0	1	04	01	H1608_029_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	029	0	1	04	01	H1608_029_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	029	0	1	04	01	H1608_029_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	029	0	1	04	01	H1608_029_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	029	0	1	04	01	H1608_029_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1232.83	33						661.06	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	031	0	1	04	01	H1608_031_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	031	0	1	04	01	H1608_031_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	031	0	1	04	01	H1608_031_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	031	0	1	04	01	H1608_031_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	031	0	1	04	01	H1608_031_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											108.80	25	25	25				97.73	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	031	0	1	04	01	H1608_031_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.67	50	50	50				44.48	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	031	0	1	04	01	H1608_031_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											841.73	29						637.01	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	037	0	1	04	01	H1608_037_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	037	0	1	04	01	H1608_037_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	037	0	1	04	01	H1608_037_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	037	0	1	04	01	H1608_037_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	037	0	1	04	01	H1608_037_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.68	25	25	25				79.07	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	037	0	1	04	01	H1608_037_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.19	50	50	50				27.82	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	037	0	1	04	01	H1608_037_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											786.23	33						564.83	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	038	0	1	04	01	H1608_038_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	038	0	1	04	01	H1608_038_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	038	0	1	04	01	H1608_038_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	038	0	1	04	01	H1608_038_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	038	0	1	04	01	H1608_038_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.89	25	25	25				80.92	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	038	0	1	04	01	H1608_038_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.27	50	50	50				25.92	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	038	0	1	04	01	H1608_038_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											885.46	33						561.29	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	040	0	1	04	01	H1608_040_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	040	0	1	04	01	H1608_040_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	040	0	1	04	01	H1608_040_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	040	0	1	04	01	H1608_040_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	040	0	1	04	01	H1608_040_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.08	25	25	25				46.76	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	040	0	1	04	01	H1608_040_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.29	50	50	50				60.45	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	040	0	1	04	01	H1608_040_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											860.48	33						623.27	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	041	0	1	04	01	H1608_041_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	041	0	1	04	01	H1608_041_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	041	0	1	04	01	H1608_041_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	041	0	1	04	01	H1608_041_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	041	0	1	04	01	H1608_041_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.39	25	25	25				51.56	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	041	0	1	04	01	H1608_041_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.90	50	50	50				61.45	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	041	0	1	04	01	H1608_041_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											927.21	33						708.09	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	043	0	1	04	01	H1608_043_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	043	0	1	04	01	H1608_043_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	043	0	1	04	01	H1608_043_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	043	0	1	04	01	H1608_043_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	043	0	1	04	01	H1608_043_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.43	25	25	25				79.95	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	043	0	1	04	01	H1608_043_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.07	50	50	50				27.41	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	043	0	1	04	01	H1608_043_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											675.59	33						550.43	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	048	0	1	04	01	H1608_048_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	048	0	1	04	01	H1608_048_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	048	0	1	04	01	H1608_048_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	048	0	1	04	01	H1608_048_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	048	0	1	04	01	H1608_048_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	048	0	1	04	01	H1608_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	048	0	1	04	01	H1608_048_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.62	33						575.15	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	050	0	1	04	01	H1608_050_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	050	0	1	04	01	H1608_050_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	050	0	1	04	01	H1608_050_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	050	0	1	04	01	H1608_050_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	050	0	1	04	01	H1608_050_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	050	0	1	04	01	H1608_050_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	050	0	1	04	01	H1608_050_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											911.17	33						670.34	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	051	0	1	04	01	H1608_051_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	051	0	1	04	01	H1608_051_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	051	0	1	04	01	H1608_051_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	051	0	1	04	01	H1608_051_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	051	0	1	04	01	H1608_051_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	051	0	1	04	01	H1608_051_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	051	0	1	04	01	H1608_051_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											673.63	30						568.09	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	052	0	1	04	01	H1608_052_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	052	0	1	04	01	H1608_052_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	052	0	1	04	01	H1608_052_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	052	0	1	04	01	H1608_052_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	052	0	1	04	01	H1608_052_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	052	0	1	04	01	H1608_052_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	052	0	1	04	01	H1608_052_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											726.30	33						621.19	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	054	0	1	04	01	H1608_054_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	054	0	1	04	01	H1608_054_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	054	0	1	04	01	H1608_054_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	054	0	1	04	01	H1608_054_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	054	0	1	04	01	H1608_054_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	054	0	1	04	01	H1608_054_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	054	0	1	04	01	H1608_054_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											735.02	33						622.66	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	064	0	1	04	01	H1608_064_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	064	0	1	04	01	H1608_064_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	064	0	1	04	01	H1608_064_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	064	0	1	04	01	H1608_064_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	064	0	1	04	01	H1608_064_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.87	25	25	25				76.03	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	064	0	1	04	01	H1608_064_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.22	50	50	50				26.32	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	064	0	1	04	01	H1608_064_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											858.75	33						645.28	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	065	0	1	04	01	H1608_065_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	065	0	1	04	01	H1608_065_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	065	0	1	04	01	H1608_065_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	065	0	1	04	01	H1608_065_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	065	0	1	04	01	H1608_065_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.56	25	25	25				75.64	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	065	0	1	04	01	H1608_065_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.07	50	50	50				25.54	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	065	0	1	04	01	H1608_065_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											892.49	33						642.10	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	067	0	1	04	01	H1608_067_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	067	0	1	04	01	H1608_067_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	067	0	1	04	01	H1608_067_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	067	0	1	04	01	H1608_067_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	067	0	1	04	01	H1608_067_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.25	25	25	25				76.98	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	067	0	1	04	01	H1608_067_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.71	50	50	50				25.84	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	067	0	1	04	01	H1608_067_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											919.75	33						655.85	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	068	0	1	04	01	H1608_068_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	068	0	1	04	01	H1608_068_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	068	0	1	04	01	H1608_068_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	068	0	1	04	01	H1608_068_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	068	0	1	04	01	H1608_068_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.50	25	25	25				75.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	068	0	1	04	01	H1608_068_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.17	50	50	50				25.52	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	068	0	1	04	01	H1608_068_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											937.10	33						642.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	070	0	1	04	01	H1608_070_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	070	0	1	04	01	H1608_070_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	070	0	1	04	01	H1608_070_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	070	0	1	04	01	H1608_070_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	070	0	1	04	01	H1608_070_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.99	25	25	25				75.58	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	070	0	1	04	01	H1608_070_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.42	50	50	50				25.95	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	070	0	1	04	01	H1608_070_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											923.39	33						646.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	071	0	1	04	01	H1608_071_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	071	0	1	04	01	H1608_071_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	071	0	1	04	01	H1608_071_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	071	0	1	04	01	H1608_071_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	071	0	1	04	01	H1608_071_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.82	25	25	25				75.45	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	071	0	1	04	01	H1608_071_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.33	50	50	50				25.79	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	071	0	1	04	01	H1608_071_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											928.28	33						645.23	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	072	0	1	04	01	H1608_072_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	072	0	1	04	01	H1608_072_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	072	0	1	04	01	H1608_072_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	072	0	1	04	01	H1608_072_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	072	0	1	04	01	H1608_072_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.99	25	25	25				75.58	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	072	0	1	04	01	H1608_072_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.42	50	50	50				25.95	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	072	0	1	04	01	H1608_072_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											923.39	33						646.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	073	0	1	04	01	H1608_073_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	073	0	1	04	01	H1608_073_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	073	0	1	04	01	H1608_073_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	073	0	1	04	01	H1608_073_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	073	0	1	04	01	H1608_073_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	073	0	1	04	01	H1608_073_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	073	0	1	04	01	H1608_073_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											863.62	33						666.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	075	0	1	04	01	H1608_075_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	075	0	1	04	01	H1608_075_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	075	0	1	04	01	H1608_075_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	075	0	1	04	01	H1608_075_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	075	0	1	04	01	H1608_075_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	075	0	1	04	01	H1608_075_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	075	0	1	04	01	H1608_075_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											677.21	30						639.05	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	078	0	1	04	01	H1608_078_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	078	0	1	04	01	H1608_078_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	078	0	1	04	01	H1608_078_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	078	0	1	04	01	H1608_078_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	078	0	1	04	01	H1608_078_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	078	0	1	04	01	H1608_078_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	078	0	1	04	01	H1608_078_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											863.62	33						666.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1608	079	0	1	04	01	H1608_079_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	079	0	1	04	01	H1608_079_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	079	0	1	04	01	H1608_079_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	079	0	1	04	01	H1608_079_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1608	079	0	1	04	01	H1608_079_0	5			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.21	25	25	25				66.64	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1608	079	0	1	04	01	H1608_079_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.16	40	40	40				74.56	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1608	079	0	1	04	01	H1608_079_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											795.62	29						602.11	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	001	0	1	02	01	H1609_001_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	001	0	1	02	01	H1609_001_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	001	0	1	02	01	H1609_001_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	001	0	1	02	01	H1609_001_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	001	0	1	02	01	H1609_001_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	001	0	1	02	01	H1609_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	001	0	1	02	01	H1609_001_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											785.51	33						725.61	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	016	0	1	01	01	H1609_016_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	016	0	1	01	01	H1609_016_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	016	0	1	01	01	H1609_016_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	016	0	1	01	01	H1609_016_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	016	0	1	01	01	H1609_016_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					3.00	6.00	9.00											47.00	94.00	141.00				3.00	6.00	9.00					47.00			47.00			1.57	0.10		1.57	0.10	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	016	0	1	01	01	H1609_016_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					85.00	170.00	255.00											100.00	200.00	300.00				85.00	170.00	255.00					100.00			100.00			3.33	2.83		3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	016	0	1	01	01	H1609_016_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.45	33						895.33	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	017	0	1	01	01	H1609_017_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	017	0	1	01	01	H1609_017_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	017	0	1	01	01	H1609_017_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.57	25	25	25				72.29	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	017	0	1	01	01	H1609_017_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.09	25	25	25				60.66	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	017	0	1	01	01	H1609_017_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.18	25						653.98	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	018	0	1	01	01	H1609_018_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	018	0	1	01	01	H1609_018_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	018	0	1	01	01	H1609_018_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	018	0	1	01	01	H1609_018_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	018	0	1	01	01	H1609_018_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					3.00	6.00	9.00											47.00	94.00	141.00				3.00	6.00	9.00					47.00			47.00			1.57	0.10		1.57	0.10	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	018	0	1	01	01	H1609_018_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					85.00	170.00	255.00											100.00	200.00	300.00				85.00	170.00	255.00					100.00			100.00			3.33	2.83		3.33	2.83	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	018	0	1	01	01	H1609_018_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											857.58	33						866.57	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	019	0	1	01	01	H1609_019_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	019	0	1	01	01	H1609_019_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	019	0	1	01	01	H1609_019_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.42	25	25	25				71.83	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	019	0	1	01	01	H1609_019_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.75	25	25	25				59.10	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	019	0	1	01	01	H1609_019_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											739.32	25						633.35	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	020	0	1	01	01	H1609_020_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	020	0	1	01	01	H1609_020_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	020	0	1	01	01	H1609_020_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	020	0	1	01	01	H1609_020_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	020	0	1	01	01	H1609_020_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					10.00	20.00	30.00											47.00	94.00	141.00				10.00	20.00	30.00					47.00			47.00			1.57	0.33		1.57	0.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	020	0	1	01	01	H1609_020_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	020	0	1	01	01	H1609_020_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											857.44	33						915.59	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	021	0	1	01	01	H1609_021_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	021	0	1	01	01	H1609_021_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	021	0	1	01	01	H1609_021_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	021	0	1	01	01	H1609_021_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	021	0	1	01	01	H1609_021_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	021	0	1	01	01	H1609_021_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	021	0	1	01	01	H1609_021_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											836.89	33						866.29	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	022	0	1	01	01	H1609_022_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	022	0	1	01	01	H1609_022_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	022	0	1	01	01	H1609_022_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	022	0	1	01	01	H1609_022_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	022	0	1	01	01	H1609_022_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					10.00	20.00	30.00											47.00	94.00	141.00				10.00	20.00	30.00					47.00			47.00			1.57	0.33		1.57	0.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	022	0	1	01	01	H1609_022_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	022	0	1	01	01	H1609_022_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.15	33						911.64	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	025	0	1	01	01	H1609_025_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	025	0	1	01	01	H1609_025_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	025	0	1	01	01	H1609_025_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	025	0	1	01	01	H1609_025_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	025	0	1	01	01	H1609_025_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	025	0	1	01	01	H1609_025_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	025	0	1	01	01	H1609_025_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											768.88	33						800.52	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	026	0	1	01	01	H1609_026_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	026	0	1	01	01	H1609_026_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	026	0	1	01	01	H1609_026_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	026	0	1	01	01	H1609_026_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	026	0	1	01	01	H1609_026_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	026	0	1	01	01	H1609_026_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	026	0	1	01	01	H1609_026_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											899.88	33						956.63	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	027	0	1	01	01	H1609_027_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	027	0	1	01	01	H1609_027_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	027	0	1	01	01	H1609_027_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	027	0	1	01	01	H1609_027_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	027	0	1	01	01	H1609_027_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	027	0	1	01	01	H1609_027_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	027	0	1	01	01	H1609_027_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											802.04	33						814.08	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	028	0	1	02	01	H1609_028_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	028	0	1	02	01	H1609_028_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	028	0	1	02	01	H1609_028_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	028	0	1	02	01	H1609_028_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	028	0	1	02	01	H1609_028_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	028	0	1	02	01	H1609_028_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	028	0	1	02	01	H1609_028_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											599.35	30						480.63	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	034	0	1	01	01	H1609_034_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	034	0	1	01	01	H1609_034_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	034	0	1	01	01	H1609_034_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	034	0	1	01	01	H1609_034_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	034	0	1	01	01	H1609_034_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					10.00	20.00	30.00											47.00	94.00	141.00				10.00	20.00	30.00					47.00			47.00			1.57	0.33		1.57	0.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	034	0	1	01	01	H1609_034_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	034	0	1	01	01	H1609_034_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											833.78	33						928.65	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	035	0	1	01	01	H1609_035_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	035	0	1	01	01	H1609_035_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	035	0	1	01	01	H1609_035_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	035	0	1	01	01	H1609_035_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	035	0	1	01	01	H1609_035_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	035	0	1	01	01	H1609_035_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	035	0	1	01	01	H1609_035_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											821.89	33						938.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	038	0	1	01	01	H1609_038_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	038	0	1	01	01	H1609_038_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	038	0	1	01	01	H1609_038_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	038	0	1	01	01	H1609_038_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	038	0	1	01	01	H1609_038_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	038	0	1	01	01	H1609_038_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	038	0	1	01	01	H1609_038_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.72	33						924.43	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	041	0	1	01	01	H1609_041_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	041	0	1	01	01	H1609_041_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	041	0	1	01	01	H1609_041_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	041	0	1	01	01	H1609_041_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	041	0	1	01	01	H1609_041_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	041	0	1	01	01	H1609_041_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	041	0	1	01	01	H1609_041_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											873.79	33						945.47	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	042	0	1	01	01	H1609_042_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	042	0	1	01	01	H1609_042_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	042	0	1	01	01	H1609_042_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	042	0	1	01	01	H1609_042_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	042	0	1	01	01	H1609_042_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	042	0	1	01	01	H1609_042_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	042	0	1	01	01	H1609_042_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											768.09	33						846.67	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	043	0	1	01	01	H1609_043_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	043	0	1	01	01	H1609_043_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	043	0	1	01	01	H1609_043_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.91	25	25	25				70.53	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	043	0	1	01	01	H1609_043_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.30	25	25	25				59.98	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	043	0	1	01	01	H1609_043_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											635.57	25						697.89	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	044	0	1	01	01	H1609_044_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	044	0	1	01	01	H1609_044_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	044	0	1	01	01	H1609_044_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.78	25	25	25				68.33	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	044	0	1	01	01	H1609_044_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.68	25	25	25				56.56	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	044	0	1	01	01	H1609_044_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											679.39	25						712.53	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	045	0	1	01	01	H1609_045_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	045	0	1	01	01	H1609_045_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	045	0	1	01	01	H1609_045_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.17	25	25	25				68.53	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	045	0	1	01	01	H1609_045_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.51	25	25	25				56.36	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	045	0	1	01	01	H1609_045_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											615.68	25						637.27	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	046	0	1	01	01	H1609_046_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	046	0	1	01	01	H1609_046_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	046	0	1	01	01	H1609_046_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.51	25	25	25				70.44	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	046	0	1	01	01	H1609_046_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.17	25	25	25				58.32	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	046	0	1	01	01	H1609_046_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											615.10	25						644.57	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	047	0	1	01	01	H1609_047_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	047	0	1	01	01	H1609_047_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	047	0	1	01	01	H1609_047_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.02	25	25	25				67.02	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	047	0	1	01	01	H1609_047_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.23	25	25	25				57.67	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	047	0	1	01	01	H1609_047_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											656.20	25						681.00	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	048	0	1	01	01	H1609_048_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	048	0	1	01	01	H1609_048_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	048	0	1	01	01	H1609_048_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.53	25	25	25				71.13	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	048	0	1	01	01	H1609_048_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.19	25	25	25				58.58	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	048	0	1	01	01	H1609_048_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											642.70	25						675.61	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	049	0	1	01	01	H1609_049_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	049	0	1	01	01	H1609_049_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	049	0	1	01	01	H1609_049_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.78	25	25	25				68.03	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	049	0	1	01	01	H1609_049_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.51	25	25	25				56.08	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	049	0	1	01	01	H1609_049_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											636.21	25						672.35	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	053	0	1	01	01	H1609_053_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	053	0	1	01	01	H1609_053_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	053	0	1	01	01	H1609_053_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	053	0	1	01	01	H1609_053_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	053	0	1	01	01	H1609_053_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.40	25	25	25				77.20	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	053	0	1	01	01	H1609_053_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.40	50	50	50				25.29	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	053	0	1	01	01	H1609_053_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											914.43	33						642.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	055	0	1	01	01	H1609_055_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	055	0	1	01	01	H1609_055_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	055	0	1	01	01	H1609_055_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.25	25	25	25				71.06	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	055	0	1	01	01	H1609_055_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.46	25	25	25				58.24	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	055	0	1	01	01	H1609_055_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											634.44	25						666.92	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	056	0	1	01	01	H1609_056_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	056	0	1	01	01	H1609_056_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	056	0	1	01	01	H1609_056_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.89	25	25	25				72.50	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	056	0	1	01	01	H1609_056_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.85	25	25	25				56.82	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	056	0	1	01	01	H1609_056_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											688.60	25						710.73	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	059	0	1	01	01	H1609_059_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	059	0	1	01	01	H1609_059_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	059	0	1	01	01	H1609_059_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	059	0	1	01	01	H1609_059_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	059	0	1	01	01	H1609_059_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	059	0	1	01	01	H1609_059_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	059	0	1	01	01	H1609_059_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											865.70	33						963.38	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	060	0	1	01	01	H1609_060_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	060	0	1	01	01	H1609_060_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	060	0	1	01	01	H1609_060_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	060	0	1	01	01	H1609_060_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	060	0	1	01	01	H1609_060_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.92	25	25	25				75.79	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	060	0	1	01	01	H1609_060_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.10	50	50	50				23.04	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	060	0	1	01	01	H1609_060_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											960.14	33						627.13	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	061	0	1	01	01	H1609_061_0	6		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	061	0	1	01	01	H1609_061_0	6		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	061	0	1	01	01	H1609_061_0	6		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.81	25	25	25				70.69	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	061	0	1	01	01	H1609_061_0	6		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.30	25	25	25				61.20	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	061	0	1	01	01	H1609_061_0	6		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											652.41	25						677.65	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	062	0	1	01	01	H1609_062_0	8		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	062	0	1	01	01	H1609_062_0	8		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	062	0	1	01	01	H1609_062_0	8		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.05	25	25	25				70.46	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	062	0	1	01	01	H1609_062_0	8		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.83	25	25	25				59.84	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	062	0	1	01	01	H1609_062_0	8		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											646.11	25						683.07	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	063	0	1	01	01	H1609_063_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	063	0	1	01	01	H1609_063_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	063	0	1	01	01	H1609_063_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	063	0	1	01	01	H1609_063_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	063	0	1	01	01	H1609_063_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00					47.00			47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	063	0	1	01	01	H1609_063_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	063	0	1	01	01	H1609_063_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											837.35	33						930.25	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	064	0	1	01	01	H1609_064_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	064	0	1	01	01	H1609_064_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	064	0	1	01	01	H1609_064_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.23	25	25	25				70.29	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	064	0	1	01	01	H1609_064_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.49	25	25	25				58.87	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	064	0	1	01	01	H1609_064_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											641.71	25						687.09	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	065	0	1	01	01	H1609_065_0	7		N	Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00					15.00			15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	065	0	1	01	01	H1609_065_0	7		N	Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00					20.00			20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H1609	065	0	1	01	01	H1609_065_0	7		N	Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.23	25	25	25				70.29	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	065	0	1	01	01	H1609_065_0	7		N	Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.49	25	25	25				58.87	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	065	0	1	01	01	H1609_065_0	7		N	Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											641.71	25						687.09	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	066	0	1	01	01	H1609_066_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	066	0	1	01	01	H1609_066_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	066	0	1	01	01	H1609_066_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	066	0	1	01	01	H1609_066_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	066	0	1	01	01	H1609_066_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					0.00	0.00	0.00											47.00	94.00	141.00				0.00	0.00	0.00					47.00			47.00			1.57	0.00		1.57	0.00	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	066	0	1	01	01	H1609_066_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					35.00	70.00	105.00											100.00	200.00	300.00				35.00	70.00	105.00					100.00			100.00			3.33	1.17		3.33	1.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	066	0	1	01	01	H1609_066_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											972.82	33						1024.38	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	067	0	1	01	01	H1609_067_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	067	0	1	01	01	H1609_067_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	067	0	1	01	01	H1609_067_0	6			Generic	4	11	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H1609	067	0	1	01	01	H1609_067_0	6			Generic	4	11	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1609	067	0	1	01	01	H1609_067_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					10.00	20.00	30.00											47.00	94.00	141.00				10.00	20.00	30.00					47.00			47.00			1.57	0.33		1.57	0.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	067	0	1	01	01	H1609_067_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00					100.00			100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	067	0	1	01	01	H1609_067_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.31	33						932.00	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	068	0	1	02	01	H1609_068_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	068	0	1	02	01	H1609_068_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	068	0	1	02	01	H1609_068_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	068	0	1	02	01	H1609_068_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	068	0	1	02	01	H1609_068_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											98.36	25	25	25				91.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	068	0	1	02	01	H1609_068_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.60	50	50	50				45.51	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	068	0	1	02	01	H1609_068_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											663.75	29						591.90	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1609	069	0	1	02	01	H1609_069_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	069	0	1	02	01	H1609_069_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	069	0	1	02	01	H1609_069_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	069	0	1	02	01	H1609_069_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1609	069	0	1	02	01	H1609_069_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.36	25	25	25				75.44	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1609	069	0	1	02	01	H1609_069_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.98	50	50	50				25.11	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1609	069	0	1	02	01	H1609_069_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											914.23	33						640.21	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1619	001	0	1	04	01	H1619_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	001	0	1	04	01	H1619_001_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	001	0	1	04	01	H1619_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H1619	001	0	1	04	01	H1619_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	001	0	1	04	01	H1619_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1011.73	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	001	0	1	04	01	H1619_001_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	001	0	1	04	01	H1619_001_0	10			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1619	002	0	1	04	01	H1619_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	002	0	1	04	01	H1619_002_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	002	0	1	04	01	H1619_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H1619	002	0	1	04	01	H1619_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	002	0	1	04	01	H1619_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				965.94	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	002	0	1	04	01	H1619_002_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1619	002	0	1	04	01	H1619_002_0	11			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1659	002	0	1	04	01	H1659_002_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1659	002	0	1	04	01	H1659_002_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1659	002	0	1	04	01	H1659_002_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1659	002	0	1	04	01	H1659_002_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1659	002	0	1	04	01	H1659_002_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1659	002	0	1	04	01	H1659_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1659	002	0	1	04	01	H1659_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1659	003	0	1	04	01	H1659_003_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1659	003	0	1	04	01	H1659_003_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1659	003	0	1	04	01	H1659_003_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1659	003	0	1	04	01	H1659_003_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1659	003	0	1	04	01	H1659_003_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1659	003	0	1	04	01	H1659_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1659	003	0	1	04	01	H1659_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				511.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1664	001	0	1	01	01	H1664_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	001	0	1	01	01	H1664_001_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1664	001	0	1	01	01	H1664_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	001	0	1	01	01	H1664_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1664	001	0	1	01	01	H1664_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											78.81	50	50	50				78.81	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1664	001	0	1	01	01	H1664_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1664	001	0	1	01	01	H1664_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	001	0	1	01	01	H1664_001_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1664	004	0	1	01	01	H1664_004_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	004	0	1	01	01	H1664_004_0	19			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1664	004	0	1	01	01	H1664_004_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	004	0	1	01	01	H1664_004_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1664	004	0	1	01	01	H1664_004_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.83	50	50	50				92.83	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1664	004	0	1	01	01	H1664_004_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1664	004	0	1	01	01	H1664_004_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	004	0	1	01	01	H1664_004_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1664	006	0	1	01	01	H1664_006_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	006	0	1	01	01	H1664_006_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	006	0	1	01	01	H1664_006_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1664	006	0	1	01	01	H1664_006_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.86	50	50	50				86.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1664	006	0	1	01	01	H1664_006_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1664	006	0	1	01	01	H1664_006_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	007	0	1	01	01	H1664_007_0	9			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	007	0	1	01	01	H1664_007_0	9			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1664	007	0	1	01	01	H1664_007_0	9			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H1664	007	0	1	01	01	H1664_007_0	9			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.57	49	49	49				98.57	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1664	007	0	1	01	01	H1664_007_0	9			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1664	007	0	1	01	01	H1664_007_0	9			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1666	003	0	1	04	01	H1666_003_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H1666	003	0	1	04	01	H1666_003_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1666	003	0	1	04	01	H1666_003_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H1666	003	0	1	04	01	H1666_003_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H1666	003	0	1	04	01	H1666_003_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	003	0	1	04	01	H1666_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	006	0	1	04	01	H1666_006_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H1666	006	0	1	04	01	H1666_006_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1666	006	0	1	04	01	H1666_006_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H1666	006	0	1	04	01	H1666_006_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H1666	006	0	1	04	01	H1666_006_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	006	0	1	04	01	H1666_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	008	0	1	04	01	H1666_008_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H1666	008	0	1	04	01	H1666_008_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1666	008	0	1	04	01	H1666_008_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H1666	008	0	1	04	01	H1666_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H1666	008	0	1	04	01	H1666_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	008	0	1	04	01	H1666_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	012	0	1	04	01	H1666_012_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H1666	012	0	1	04	01	H1666_012_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H1666	012	0	1	04	01	H1666_012_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	012	0	1	04	01	H1666_012_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	012	0	1	04	01	H1666_012_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	013	0	1	04	01	H1666_013_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H1666	013	0	1	04	01	H1666_013_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H1666	013	0	1	04	01	H1666_013_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	013	0	1	04	01	H1666_013_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	013	0	1	04	01	H1666_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	014	0	1	04	01	H1666_014_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H1666	014	0	1	04	01	H1666_014_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H1666	014	0	1	04	01	H1666_014_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	014	0	1	04	01	H1666_014_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	014	0	1	04	01	H1666_014_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	015	0	1	04	01	H1666_015_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H1666	015	0	1	04	01	H1666_015_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H1666	015	0	1	04	01	H1666_015_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	015	0	1	04	01	H1666_015_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	015	0	1	04	01	H1666_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	016	0	1	04	01	H1666_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H1666	016	0	1	04	01	H1666_016_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H1666	016	0	1	04	01	H1666_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	016	0	1	04	01	H1666_016_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	016	0	1	04	01	H1666_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1666	018	0	1	04	01	H1666_018_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H1666	018	0	1	04	01	H1666_018_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H1666	018	0	1	04	01	H1666_018_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	018	0	1	04	01	H1666_018_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1666	018	0	1	04	01	H1666_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	002	0	1	02	01	H1692_002_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	002	0	1	02	01	H1692_002_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1692	002	0	1	02	01	H1692_002_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	002	0	1	02	01	H1692_002_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1692	002	0	1	02	01	H1692_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1692	002	0	1	02	01	H1692_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	002	0	1	02	01	H1692_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											755.44	33						733.75	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1692	003	0	1	02	01	H1692_003_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	003	0	1	02	01	H1692_003_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1692	003	0	1	02	01	H1692_003_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	003	0	1	02	01	H1692_003_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1692	003	0	1	02	01	H1692_003_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.96	25	25	25				46.78	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1692	003	0	1	02	01	H1692_003_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.57	50	50	50				65.49	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	003	0	1	02	01	H1692_003_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											874.42	33						734.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1692	007	0	1	02	01	H1692_007_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	007	0	1	02	01	H1692_007_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1692	007	0	1	02	01	H1692_007_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	007	0	1	02	01	H1692_007_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1692	007	0	1	02	01	H1692_007_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.06	25	25	25				48.39	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1692	007	0	1	02	01	H1692_007_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.57	50	50	50				62.48	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1692	007	0	1	02	01	H1692_007_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											860.33	33						648.64	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H1722	002	0	1	01	01	H1722_002_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1722	002	0	1	01	01	H1722_002_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	10.00																			10.00	20.00	10.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													10.00	20.00	10.00				10.00	20.00	10.00				10.00		10.00
H1722	002	0	1	01	01	H1722_002_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	47.00																			47.00	94.00	47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H1722	002	0	1	01	01	H1722_002_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H1722	002	0	1	01	01	H1722_002_0	12			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H1722	002	0	1	01	01	H1722_002_0	12			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H1722	002	0	1	01	01	H1722_002_0	12			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H1723	001	0	1	48	05	H1723_001_0	13			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H1723	001	0	1	48	05	H1723_001_0	13			Brand Drugs	4	10		2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H1723	001	0	1	48	05	H1723_001_0	13			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H1737	001	0	1	01	01	H1737_001_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1737	001	0	1	01	01	H1737_001_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1737	001	0	1	01	01	H1737_001_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H1737	001	0	1	01	01	H1737_001_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1737	001	0	1	01	01	H1737_001_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				72.14	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1737	001	0	1	01	01	H1737_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	001	0	1	01	01	H1748_001_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	001	0	1	01	01	H1748_001_0	10			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1748	001	0	1	01	01	H1748_001_0	10			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		31	10.00		30.00																					0.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	001	0	1	01	01	H1748_001_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	44.00		132.00																					88.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		70.00						70.00				35.00		35.00
H1748	001	0	1	01	01	H1748_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	2			90				30		31	95.00		285.00																					285.00																95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	001	0	1	01	01	H1748_001_0	10			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		90				2	2			90				30		31				1136.36	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	003	0	1	01	01	H1748_003_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	003	0	1	01	01	H1748_003_0	10			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		31	15.00		45.00																					0.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	003	0	1	01	01	H1748_003_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	47.00		141.00																					141.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H1748	003	0	1	01	01	H1748_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	003	0	1	01	01	H1748_003_0	10			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		90				2	2			90				30		31				1087.96	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	003	0	1	01	01	H1748_003_0	10			Select Care Drugs	4	01	1	2	6	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	004	0	1	01	01	H1748_004_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	004	0	1	01	01	H1748_004_0	10			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		31	15.00		45.00																					0.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	004	0	1	01	01	H1748_004_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	47.00		141.00																					141.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H1748	004	0	1	01	01	H1748_004_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	004	0	1	01	01	H1748_004_0	10			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		90				2	2			90				30		31				1095.77	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	004	0	1	01	01	H1748_004_0	10			Select Care Drugs	4	01	1	2	6	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1748	005	0	1	01	01	H1748_005_0	12		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	005	0	1	01	01	H1748_005_0	12		N	Generic	4	01	3	1	2	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	005	0	1	01	01	H1748_005_0	12		N	Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		70.00						70.00				35.00		35.00
H1748	005	0	1	01	01	H1748_005_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	005	0	1	01	01	H1748_005_0	12		N	Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		90				2	2			90				30		31					25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	010	0	1	01	01	H1748_010_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	010	0	1	01	01	H1748_010_0	10			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1748	010	0	1	01	01	H1748_010_0	10			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		31	10.00		30.00																					0.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	010	0	1	01	01	H1748_010_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	44.00		132.00																					88.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		70.00						70.00				35.00		35.00
H1748	010	0	1	01	01	H1748_010_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	2			90				30		31	95.00		285.00																					285.00																95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1748	010	0	1	01	01	H1748_010_0	10			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		90				2	2			90				30		31				1136.36	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1774	001	0	1	04	01	H1774_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1774	001	0	1	04	01	H1774_001_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1774	001	0	1	04	01	H1774_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1774	001	0	1	04	01	H1774_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											79.51	50	50	50				79.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1774	001	0	1	04	01	H1774_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1774	001	0	1	04	01	H1774_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1787	002	0	1	01	01	H1787_002_0	9			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	4.00	8.00	12.00																																						4.00			4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1787	002	0	1	01	01	H1787_002_0	9			Generic	4	01	1	2	2	1	111		10			1	30	60	90				2	2								10	31	10.00	20.00	30.00																																						10.00			10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1787	002	0	1	01	01	H1787_002_0	9			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				2	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00										35.00		35.00
H1787	002	0	1	01	01	H1787_002_0	9			Non-Preferred Drug	4	10	1	2	4	1	111		10			1	30	60	90				2	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00										35.00		35.00
H1787	002	0	1	01	01	H1787_002_0	9			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31					33	33	33																																				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1787	002	0	1	01	01	H1787_002_0	9			Select Care Drugs	4	11	1	2	6	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1799	002	0	1	01	01	H1799_002_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1799	002	0	1	01	01	H1799_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1799	002	0	1	01	01	H1799_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H1799	002	0	1	01	01	H1799_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1799	002	0	1	01	01	H1799_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1039.04	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H1799	002	0	1	01	01	H1799_002_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	001	0	1	01	01	H1822_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	001	0	1	01	01	H1822_001_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1822	001	0	1	01	01	H1822_001_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	001	0	1	01	01	H1822_001_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	001	0	1	01	01	H1822_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H1822	001	0	1	01	01	H1822_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	001	0	1	01	01	H1822_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	001	0	1	01	01	H1822_001_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	002	0	1	01	01	H1822_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	002	0	1	01	01	H1822_002_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	002	0	1	01	01	H1822_002_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	002	0	1	01	01	H1822_002_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	002	0	1	01	01	H1822_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H1822	002	0	1	01	01	H1822_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	002	0	1	01	01	H1822_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	002	0	1	01	01	H1822_002_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	003	0	1	01	01	H1822_003_0	10			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	003	0	1	01	01	H1822_003_0	10			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	003	0	1	01	01	H1822_003_0	10			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	003	0	1	01	01	H1822_003_0	10			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	003	0	1	01	01	H1822_003_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H1822	003	0	1	01	01	H1822_003_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	003	0	1	01	01	H1822_003_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	003	0	1	01	01	H1822_003_0	10			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	004	0	1	01	01	H1822_004_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	004	0	1	01	01	H1822_004_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1822	004	0	1	01	01	H1822_004_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	004	0	1	01	01	H1822_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H1822	004	0	1	01	01	H1822_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	004	0	1	01	01	H1822_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	004	0	1	01	01	H1822_004_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	005	0	1	02	01	H1822_005_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	005	0	1	02	01	H1822_005_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	005	0	1	02	01	H1822_005_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	005	0	1	02	01	H1822_005_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1822	005	0	1	02	01	H1822_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								37.00	74.00	91.00					37.00	74.00	91.00											37.00	74.00	91.00				37.00	74.00	91.00				37.00				37.00			1.23	1.23		1.23	1.23	1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H1822	005	0	1	02	01	H1822_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					99.00	198.00	277.00											100.00	200.00	280.00				99.00	198.00	277.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	005	0	1	02	01	H1822_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1822	005	0	1	02	01	H1822_005_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1846	004	0	1	04	01	H1846_004_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	4.00	6.00				0.00	0.00	0.00				2.00		2.00
H1846	004	0	1	04	01	H1846_004_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1846	004	0	1	04	01	H1846_004_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H1846	004	0	1	04	01	H1846_004_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	004	0	1	04	01	H1846_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	004	0	1	04	01	H1846_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1846	005	0	1	04	01	H1846_005_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1846	005	0	1	04	01	H1846_005_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1846	005	0	1	04	01	H1846_005_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H1846	005	0	1	04	01	H1846_005_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	005	0	1	04	01	H1846_005_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	005	0	1	04	01	H1846_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1846	006	0	1	04	01	H1846_006_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1846	006	0	1	04	01	H1846_006_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1846	006	0	1	04	01	H1846_006_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H1846	006	0	1	04	01	H1846_006_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	006	0	1	04	01	H1846_006_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	006	0	1	04	01	H1846_006_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1846	007	0	1	04	01	H1846_007_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1846	007	0	1	04	01	H1846_007_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1846	007	0	1	04	01	H1846_007_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H1846	007	0	1	04	01	H1846_007_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	007	0	1	04	01	H1846_007_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H1846	007	0	1	04	01	H1846_007_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H1848	001	0	1	04	01	H1848_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1848	001	0	1	04	01	H1848_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1848	001	0	1	04	01	H1848_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1848	001	0	1	04	01	H1848_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.02	50	50	50				77.02	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1848	001	0	1	04	01	H1848_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1848	001	0	1	04	01	H1848_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1848	001	0	1	04	01	H1848_001_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1848	002	0	1	04	01	H1848_002_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1848	002	0	1	04	01	H1848_002_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1848	002	0	1	04	01	H1848_002_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1848	002	0	1	04	01	H1848_002_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.17	50	50	50				86.17	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1848	002	0	1	04	01	H1848_002_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1848	002	0	1	04	01	H1848_002_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1848	002	0	1	04	01	H1848_002_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1862	001	0	1	01	01	H1862_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1862	001	0	1	01	01	H1862_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1862	001	0	1	01	01	H1862_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1862	001	0	1	01	01	H1862_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.59	50	50	50				90.59	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1862	001	0	1	01	01	H1862_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1862	001	0	1	01	01	H1862_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1889	013	0	1	04	01	H1889_013_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	013	0	1	04	01	H1889_013_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	013	0	1	04	01	H1889_013_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	013	0	1	04	01	H1889_013_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	013	0	1	04	01	H1889_013_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	013	0	1	04	01	H1889_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	013	0	1	04	01	H1889_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				290.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	014	0	1	04	01	H1889_014_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	014	0	1	04	01	H1889_014_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	014	0	1	04	01	H1889_014_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	014	0	1	04	01	H1889_014_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	014	0	1	04	01	H1889_014_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	014	0	1	04	01	H1889_014_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	014	0	1	04	01	H1889_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				493.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	015	0	1	04	01	H1889_015_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	015	0	1	04	01	H1889_015_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	015	0	1	04	01	H1889_015_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	015	0	1	04	01	H1889_015_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	015	0	1	04	01	H1889_015_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	015	0	1	04	01	H1889_015_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	015	0	1	04	01	H1889_015_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				449.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	016	0	1	04	01	H1889_016_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	016	0	1	04	01	H1889_016_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	016	0	1	04	01	H1889_016_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	016	0	1	04	01	H1889_016_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	016	0	1	04	01	H1889_016_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	016	0	1	04	01	H1889_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	016	0	1	04	01	H1889_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				427.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	017	0	1	04	01	H1889_017_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	017	0	1	04	01	H1889_017_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	017	0	1	04	01	H1889_017_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	017	0	1	04	01	H1889_017_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	017	0	1	04	01	H1889_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	017	0	1	04	01	H1889_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	017	0	1	04	01	H1889_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				502.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	019	0	1	04	01	H1889_019_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	019	0	1	04	01	H1889_019_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	019	0	1	04	01	H1889_019_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	019	0	1	04	01	H1889_019_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	019	0	1	04	01	H1889_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H1889	019	0	1	04	01	H1889_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	019	0	1	04	01	H1889_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	020	0	1	04	01	H1889_020_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	020	0	1	04	01	H1889_020_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	020	0	1	04	01	H1889_020_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	020	0	1	04	01	H1889_020_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	020	0	1	04	01	H1889_020_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H1889	020	0	1	04	01	H1889_020_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	020	0	1	04	01	H1889_020_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				459.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	021	0	1	04	01	H1889_021_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	021	0	1	04	01	H1889_021_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	021	0	1	04	01	H1889_021_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	021	0	1	04	01	H1889_021_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	021	0	1	04	01	H1889_021_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	021	0	1	04	01	H1889_021_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	021	0	1	04	01	H1889_021_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				271.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	023	0	1	04	01	H1889_023_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	023	0	1	04	01	H1889_023_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1889	023	0	1	04	01	H1889_023_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1889	023	0	1	04	01	H1889_023_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1889	023	0	1	04	01	H1889_023_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	023	0	1	04	01	H1889_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1889	023	0	1	04	01	H1889_023_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				579.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1894	008	0	1	01	01	H1894_008_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1894	008	0	1	01	01	H1894_008_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1894	008	0	1	01	01	H1894_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1894	008	0	1	01	01	H1894_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1894	008	0	1	01	01	H1894_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1894	008	0	1	01	01	H1894_008_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1894	008	0	1	01	01	H1894_008_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1914	001	0	1	04	01	H1914_001_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1914	001	0	1	04	01	H1914_001_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1914	001	0	1	04	01	H1914_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H1914	001	0	1	04	01	H1914_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.76	38	38	38				97.76	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1914	001	0	1	04	01	H1914_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H1914	001	0	1	04	01	H1914_001_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1914	001	0	1	04	01	H1914_001_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1914	002	0	1	04	01	H1914_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1914	002	0	1	04	01	H1914_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1914	002	0	1	04	01	H1914_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H1914	002	0	1	04	01	H1914_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.58	47	47	47				99.58	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H1914	002	0	1	04	01	H1914_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H1914	002	0	1	04	01	H1914_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1914	002	0	1	04	01	H1914_002_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H1944	001	0	1	02	01	H1944_001_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	001	0	1	02	01	H1944_001_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	001	0	1	02	01	H1944_001_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	001	0	1	02	01	H1944_001_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	001	0	1	02	01	H1944_001_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	001	0	1	02	01	H1944_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	001	0	1	02	01	H1944_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				338.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	004	0	1	02	01	H1944_004_0	8			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	004	0	1	02	01	H1944_004_0	8			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	004	0	1	02	01	H1944_004_0	8			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	004	0	1	02	01	H1944_004_0	8			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	004	0	1	02	01	H1944_004_0	8			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	004	0	1	02	01	H1944_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	004	0	1	02	01	H1944_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				243.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	005	0	1	02	01	H1944_005_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	005	0	1	02	01	H1944_005_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	005	0	1	02	01	H1944_005_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	005	0	1	02	01	H1944_005_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	005	0	1	02	01	H1944_005_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	005	0	1	02	01	H1944_005_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	005	0	1	02	01	H1944_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				410.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	006	0	1	02	01	H1944_006_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	006	0	1	02	01	H1944_006_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	006	0	1	02	01	H1944_006_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	006	0	1	02	01	H1944_006_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	006	0	1	02	01	H1944_006_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	006	0	1	02	01	H1944_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	006	0	1	02	01	H1944_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				226.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	009	0	1	02	01	H1944_009_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	009	0	1	02	01	H1944_009_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	009	0	1	02	01	H1944_009_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	009	0	1	02	01	H1944_009_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1944	009	0	1	02	01	H1944_009_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	009	0	1	02	01	H1944_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	009	0	1	02	01	H1944_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				585.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	010	0	1	02	01	H1944_010_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	010	0	1	02	01	H1944_010_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	010	0	1	02	01	H1944_010_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	010	0	1	02	01	H1944_010_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	010	0	1	02	01	H1944_010_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	010	0	1	02	01	H1944_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	010	0	1	02	01	H1944_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				469.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	011	0	1	02	01	H1944_011_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	011	0	1	02	01	H1944_011_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	011	0	1	02	01	H1944_011_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	011	0	1	02	01	H1944_011_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1944	011	0	1	02	01	H1944_011_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	011	0	1	02	01	H1944_011_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	011	0	1	02	01	H1944_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				464.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	014	0	1	02	01	H1944_014_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	014	0	1	02	01	H1944_014_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	014	0	1	02	01	H1944_014_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	9.00		18.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	014	0	1	02	01	H1944_014_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	9.00		18.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	014	0	1	02	01	H1944_014_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	014	0	1	02	01	H1944_014_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	014	0	1	02	01	H1944_014_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				436.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	016	0	1	02	01	H1944_016_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	016	0	1	02	01	H1944_016_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	016	0	1	02	01	H1944_016_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	9.00		18.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	016	0	1	02	01	H1944_016_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	9.00		18.00																											27.00						0.00				9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	016	0	1	02	01	H1944_016_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	016	0	1	02	01	H1944_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	016	0	1	02	01	H1944_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				681.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	017	0	1	02	01	H1944_017_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	017	0	1	02	01	H1944_017_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	017	0	1	02	01	H1944_017_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	017	0	1	02	01	H1944_017_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	017	0	1	02	01	H1944_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	017	0	1	02	01	H1944_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	017	0	1	02	01	H1944_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				615.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	018	0	1	02	01	H1944_018_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	018	0	1	02	01	H1944_018_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	018	0	1	02	01	H1944_018_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	018	0	1	02	01	H1944_018_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	018	0	1	02	01	H1944_018_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	018	0	1	02	01	H1944_018_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	018	0	1	02	01	H1944_018_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				231.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	024	0	1	02	01	H1944_024_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	024	0	1	02	01	H1944_024_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	024	0	1	02	01	H1944_024_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	024	0	1	02	01	H1944_024_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1944	024	0	1	02	01	H1944_024_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	024	0	1	02	01	H1944_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	024	0	1	02	01	H1944_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				635.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	031	0	1	02	01	H1944_031_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	031	0	1	02	01	H1944_031_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	031	0	1	02	01	H1944_031_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	031	0	1	02	01	H1944_031_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	031	0	1	02	01	H1944_031_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	031	0	1	02	01	H1944_031_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	031	0	1	02	01	H1944_031_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				428.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	032	0	1	02	01	H1944_032_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	032	0	1	02	01	H1944_032_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	032	0	1	02	01	H1944_032_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	032	0	1	02	01	H1944_032_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	032	0	1	02	01	H1944_032_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	032	0	1	02	01	H1944_032_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	032	0	1	02	01	H1944_032_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				703.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	033	0	1	02	01	H1944_033_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	033	0	1	02	01	H1944_033_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	033	0	1	02	01	H1944_033_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	033	0	1	02	01	H1944_033_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	033	0	1	02	01	H1944_033_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	033	0	1	02	01	H1944_033_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	033	0	1	02	01	H1944_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				568.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	034	0	1	02	01	H1944_034_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	034	0	1	02	01	H1944_034_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	034	0	1	02	01	H1944_034_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	034	0	1	02	01	H1944_034_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	034	0	1	02	01	H1944_034_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	034	0	1	02	01	H1944_034_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	034	0	1	02	01	H1944_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				414.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	035	0	1	02	01	H1944_035_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	035	0	1	02	01	H1944_035_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1944	035	0	1	02	01	H1944_035_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1944	035	0	1	02	01	H1944_035_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H1944	035	0	1	02	01	H1944_035_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	035	0	1	02	01	H1944_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H1944	035	0	1	02	01	H1944_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				454.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1951	013	0	1	01	01	H1951_013_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	013	0	1	01	01	H1951_013_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	013	0	1	01	01	H1951_013_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	013	0	1	01	01	H1951_013_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	013	0	1	01	01	H1951_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	024	0	1	01	01	H1951_024_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	024	0	1	01	01	H1951_024_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	024	0	1	01	01	H1951_024_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	024	0	1	01	01	H1951_024_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	024	0	1	01	01	H1951_024_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	028	0	1	01	01	H1951_028_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	028	0	1	01	01	H1951_028_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	028	0	1	01	01	H1951_028_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	028	0	1	01	01	H1951_028_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	028	0	1	01	01	H1951_028_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	038	0	1	01	01	H1951_038_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	038	0	1	01	01	H1951_038_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	038	0	1	01	01	H1951_038_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	038	0	1	01	01	H1951_038_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	038	0	1	01	01	H1951_038_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	039	0	1	01	01	H1951_039_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	039	0	1	01	01	H1951_039_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	039	0	1	01	01	H1951_039_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	039	0	1	01	01	H1951_039_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	039	0	1	01	01	H1951_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	044	0	1	01	01	H1951_044_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	044	0	1	01	01	H1951_044_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1951	044	0	1	01	01	H1951_044_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H1951	044	0	1	01	01	H1951_044_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H1951	044	0	1	01	01	H1951_044_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	044	0	1	01	01	H1951_044_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1951	044	0	1	01	01	H1951_044_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	044	0	1	01	01	H1951_044_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1951	044	0	1	01	01	H1951_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H1951	044	0	1	01	01	H1951_044_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H1951	044	0	1	01	01	H1951_044_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H1951	044	0	1	01	01	H1951_044_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1951	047	1	1	01	01	H1951_047_1	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	047	1	1	01	01	H1951_047_1	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	047	1	1	01	01	H1951_047_1	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	047	1	1	01	01	H1951_047_1	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	047	1	1	01	01	H1951_047_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	047	2	1	01	01	H1951_047_2	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	047	2	1	01	01	H1951_047_2	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	047	2	1	01	01	H1951_047_2	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	047	2	1	01	01	H1951_047_2	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	047	2	1	01	01	H1951_047_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	048	1	1	01	01	H1951_048_1	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	048	1	1	01	01	H1951_048_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	048	1	1	01	01	H1951_048_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	048	1	1	01	01	H1951_048_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	048	1	1	01	01	H1951_048_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	048	2	1	01	01	H1951_048_2	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	048	2	1	01	01	H1951_048_2	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	048	2	1	01	01	H1951_048_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	048	2	1	01	01	H1951_048_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	048	2	1	01	01	H1951_048_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	049	1	1	01	01	H1951_049_1	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	049	1	1	01	01	H1951_049_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	049	1	1	01	01	H1951_049_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	049	1	1	01	01	H1951_049_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	049	1	1	01	01	H1951_049_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	049	2	1	01	01	H1951_049_2	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	049	2	1	01	01	H1951_049_2	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	049	2	1	01	01	H1951_049_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	049	2	1	01	01	H1951_049_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	049	2	1	01	01	H1951_049_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	049	3	1	01	01	H1951_049_3	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	049	3	1	01	01	H1951_049_3	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	049	3	1	01	01	H1951_049_3	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	049	3	1	01	01	H1951_049_3	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	049	3	1	01	01	H1951_049_3	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	051	0	1	01	01	H1951_051_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	051	0	1	01	01	H1951_051_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	051	0	1	01	01	H1951_051_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	051	0	1	01	01	H1951_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	051	0	1	01	01	H1951_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	052	0	1	01	01	H1951_052_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	052	0	1	01	01	H1951_052_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	052	0	1	01	01	H1951_052_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	052	0	1	01	01	H1951_052_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	052	0	1	01	01	H1951_052_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	053	0	1	01	01	H1951_053_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	053	0	1	01	01	H1951_053_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	053	0	1	01	01	H1951_053_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	053	0	1	01	01	H1951_053_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	053	0	1	01	01	H1951_053_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	054	0	1	01	01	H1951_054_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	054	0	1	01	01	H1951_054_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H1951	054	0	1	01	01	H1951_054_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	054	0	1	01	01	H1951_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	054	0	1	01	01	H1951_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				35.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1951	055	0	1	01	01	H1951_055_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H1951	055	0	1	01	01	H1951_055_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H1951	055	0	1	01	01	H1951_055_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	055	0	1	01	01	H1951_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H1951	055	0	1	01	01	H1951_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H1961	014	1	1	02	01	H1961_014_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	1	1	02	01	H1961_014_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1961	014	1	1	02	01	H1961_014_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	1	1	02	01	H1961_014_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1961	014	1	1	02	01	H1961_014_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	1	1	02	01	H1961_014_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	1	1	02	01	H1961_014_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				435.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	2	1	02	01	H1961_014_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	2	1	02	01	H1961_014_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1961	014	2	1	02	01	H1961_014_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	2	1	02	01	H1961_014_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1961	014	2	1	02	01	H1961_014_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	2	1	02	01	H1961_014_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	2	1	02	01	H1961_014_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				435.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	3	1	02	01	H1961_014_3	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	3	1	02	01	H1961_014_3	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1961	014	3	1	02	01	H1961_014_3	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	3	1	02	01	H1961_014_3	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1961	014	3	1	02	01	H1961_014_3	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	3	1	02	01	H1961_014_3	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	3	1	02	01	H1961_014_3	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				435.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	4	1	02	01	H1961_014_4	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	4	1	02	01	H1961_014_4	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1961	014	4	1	02	01	H1961_014_4	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	014	4	1	02	01	H1961_014_4	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1961	014	4	1	02	01	H1961_014_4	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	4	1	02	01	H1961_014_4	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	014	4	1	02	01	H1961_014_4	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				435.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	017	0	1	02	01	H1961_017_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	017	0	1	02	01	H1961_017_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1961	017	0	1	02	01	H1961_017_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	017	0	1	02	01	H1961_017_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1961	017	0	1	02	01	H1961_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	017	0	1	02	01	H1961_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	017	0	1	02	01	H1961_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				695.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	020	0	1	02	01	H1961_020_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	020	0	1	02	01	H1961_020_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1961	020	0	1	02	01	H1961_020_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1961	020	0	1	02	01	H1961_020_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H1961	020	0	1	02	01	H1961_020_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	020	0	1	02	01	H1961_020_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H1961	020	0	1	02	01	H1961_020_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				435.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1969	002	0	1	01	01	H1969_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1969	002	0	1	01	01	H1969_002_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H1969	002	0	1	01	01	H1969_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1969	002	0	1	01	01	H1969_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1969	002	0	1	01	01	H1969_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1969	007	3	1	01	01	H1969_007_3	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1969	007	3	1	01	01	H1969_007_3	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H1969	007	3	1	01	01	H1969_007_3	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1969	007	3	1	01	01	H1969_007_3	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1969	007	3	1	01	01	H1969_007_3	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1149.44	31						1149.44	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1969	007	4	1	01	01	H1969_007_4	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1969	007	4	1	01	01	H1969_007_4	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H1969	007	4	1	01	01	H1969_007_4	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1969	007	4	1	01	01	H1969_007_4	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1969	007	4	1	01	01	H1969_007_4	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1149.44	31						1149.44	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1977	001	0	1	48	05	H1977_001_0	4			Generic Drugs	4	01		2	1	1	010		01			1	30														30		31																																														0.00						0.00	Generic Drugs, Brand Drugs	3	0.00	0.00	0.00	0.00			0.00	0.00																		
H1977	001	0	1	48	05	H1977_001_0	4			Brand Drugs	4	10		2	2	1	010		01			1	30														30		31																																														0.00						0.00	Generic Drugs, Brand Drugs	3	0.00	0.00	0.00	0.00			0.00	0.00																		
H1993	001	0	1	01	01	H1993_001_0	10			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	001	0	1	01	01	H1993_001_0	10			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	001	0	1	01	01	H1993_001_0	10			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	001	0	1	01	01	H1993_001_0	10			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1993	001	0	1	01	01	H1993_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	001	0	1	01	01	H1993_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	98.00																																							98.00				98.00		3.27						3.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H1993	001	0	1	01	01	H1993_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1040.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	001	0	1	01	01	H1993_001_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	001	0	1	01	01	H1993_001_0	10			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	007	0	1	01	01	H1993_007_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	007	0	1	01	01	H1993_007_0	12			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	007	0	1	01	01	H1993_007_0	12			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	007	0	1	01	01	H1993_007_0	12			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1993	007	0	1	01	01	H1993_007_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	28.00	56.00	84.00																			28.00	56.00	84.00																28.00				28.00		0.93			0.93			0.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	007	0	1	01	01	H1993_007_0	12			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H1993	007	0	1	01	01	H1993_007_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1040.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	007	0	1	01	01	H1993_007_0	12			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	007	0	1	01	01	H1993_007_0	12			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	008	0	1	01	01	H1993_008_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	008	0	1	01	01	H1993_008_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	008	0	1	01	01	H1993_008_0	11			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	36.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	36.00				12.00	24.00	36.00				12.00		12.00
H1993	008	0	1	01	01	H1993_008_0	11			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	36.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1993	008	0	1	01	01	H1993_008_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	35.00	70.00	105.00																			35.00	70.00	105.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1993	008	0	1	01	01	H1993_008_0	11			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	95.00																																							95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H1993	008	0	1	01	01	H1993_008_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1040.44	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	008	0	1	01	01	H1993_008_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	008	0	1	01	01	H1993_008_0	11			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	010	0	1	01	01	H1993_010_0	13			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	010	0	1	01	01	H1993_010_0	13			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1993	010	0	1	01	01	H1993_010_0	13			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	010	0	1	01	01	H1993_010_0	13			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H1993	010	0	1	01	01	H1993_010_0	13			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	35.00	70.00	105.00																			35.00	70.00	105.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H1993	010	0	1	01	01	H1993_010_0	13			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	95.00																																							95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H1993	010	0	1	01	01	H1993_010_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1040.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	010	0	1	01	01	H1993_010_0	13			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H1993	010	0	1	01	01	H1993_010_0	13			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H1994	001	0	1	01	01	H1994_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	001	0	1	01	01	H1994_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	001	0	1	01	01	H1994_001_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	001	0	1	01	01	H1994_001_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	001	0	1	01	01	H1994_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	001	0	1	01	01	H1994_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	001	0	1	01	01	H1994_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1113.70	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	002	0	1	01	01	H1994_002_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	002	0	1	01	01	H1994_002_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	002	0	1	01	01	H1994_002_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	002	0	1	01	01	H1994_002_0	13			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	002	0	1	01	01	H1994_002_0	13			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	002	0	1	01	01	H1994_002_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	002	0	1	01	01	H1994_002_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1134.76	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	003	0	1	01	01	H1994_003_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	003	0	1	01	01	H1994_003_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	003	0	1	01	01	H1994_003_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	003	0	1	01	01	H1994_003_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	003	0	1	01	01	H1994_003_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	003	0	1	01	01	H1994_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	003	0	1	01	01	H1994_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1284.97	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	004	0	1	01	01	H1994_004_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	004	0	1	01	01	H1994_004_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	004	0	1	01	01	H1994_004_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	004	0	1	01	01	H1994_004_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	004	0	1	01	01	H1994_004_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	004	0	1	01	01	H1994_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	004	0	1	01	01	H1994_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1293.99	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	007	0	1	01	01	H1994_007_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1994	007	0	1	01	01	H1994_007_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	3																
H1994	007	0	1	01	01	H1994_007_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			6.00	12.00	18.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1994	007	0	1	01	01	H1994_007_0	12			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			6.00	12.00	18.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	3																
H1994	007	0	1	01	01	H1994_007_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	007	0	1	01	01	H1994_007_0	12			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	007	0	1	01	01	H1994_007_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				798.68	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1994	008	0	1	01	01	H1994_008_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1994	008	0	1	01	01	H1994_008_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	3																
H1994	008	0	1	01	01	H1994_008_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1994	008	0	1	01	01	H1994_008_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	3																
H1994	008	0	1	01	01	H1994_008_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	008	0	1	01	01	H1994_008_0	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	008	0	1	01	01	H1994_008_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1151.89	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H1994	012	0	1	01	01	H1994_012_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	012	0	1	01	01	H1994_012_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1994	012	0	1	01	01	H1994_012_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	012	0	1	01	01	H1994_012_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	012	0	1	01	01	H1994_012_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	012	0	1	01	01	H1994_012_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	012	0	1	01	01	H1994_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				818.21	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	013	0	1	01	01	H1994_013_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	013	0	1	01	01	H1994_013_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	013	0	1	01	01	H1994_013_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	013	0	1	01	01	H1994_013_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	013	0	1	01	01	H1994_013_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	013	0	1	01	01	H1994_013_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	013	0	1	01	01	H1994_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				3239.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	014	0	1	01	01	H1994_014_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	014	0	1	01	01	H1994_014_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	014	0	1	01	01	H1994_014_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	014	0	1	01	01	H1994_014_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	014	0	1	01	01	H1994_014_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	014	0	1	01	01	H1994_014_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	014	0	1	01	01	H1994_014_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1372.07	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	017	0	1	01	01	H1994_017_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	017	0	1	01	01	H1994_017_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	017	0	1	01	01	H1994_017_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	15.00	30.00	45.00																			0.00	0.00	0.00																15.00				15.00		0.50			0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	017	0	1	01	01	H1994_017_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	15.00	30.00	45.00																			0.00	0.00	0.00																15.00				15.00		0.50			0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	017	0	1	01	01	H1994_017_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	017	0	1	01	01	H1994_017_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	017	0	1	01	01	H1994_017_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				884.10	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	021	0	1	01	01	H1994_021_0	7			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	021	0	1	01	01	H1994_021_0	7			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H1994	021	0	1	01	01	H1994_021_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	021	0	1	01	01	H1994_021_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	021	0	1	01	01	H1994_021_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	021	0	1	01	01	H1994_021_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	270.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	021	0	1	01	01	H1994_021_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											818.21	33						818.21	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	022	0	1	01	01	H1994_022_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	022	0	1	01	01	H1994_022_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	022	0	1	01	01	H1994_022_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	022	0	1	01	01	H1994_022_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	022	0	1	01	01	H1994_022_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	022	0	1	01	01	H1994_022_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	270.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	022	0	1	01	01	H1994_022_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1113.70	33						1113.70	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	023	0	1	01	01	H1994_023_0	7			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	023	0	1	01	01	H1994_023_0	7			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	023	0	1	01	01	H1994_023_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	023	0	1	01	01	H1994_023_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	023	0	1	01	01	H1994_023_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	023	0	1	01	01	H1994_023_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	270.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	023	0	1	01	01	H1994_023_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1284.97	31						1284.97	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	024	0	1	01	01	H1994_024_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	024	0	1	01	01	H1994_024_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	024	0	1	01	01	H1994_024_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	024	0	1	01	01	H1994_024_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	024	0	1	01	01	H1994_024_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	024	0	1	01	01	H1994_024_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	024	0	1	01	01	H1994_024_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1284.97	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	025	0	1	01	01	H1994_025_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	025	0	1	01	01	H1994_025_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	025	0	1	01	01	H1994_025_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	025	0	1	01	01	H1994_025_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	025	0	1	01	01	H1994_025_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	025	0	1	01	01	H1994_025_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	025	0	1	01	01	H1994_025_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1372.07	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	027	0	1	01	01	H1994_027_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	027	0	1	01	01	H1994_027_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	027	0	1	01	01	H1994_027_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	027	0	1	01	01	H1994_027_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	027	0	1	01	01	H1994_027_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	027	0	1	01	01	H1994_027_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	027	0	1	01	01	H1994_027_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1113.70	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	029	0	1	01	01	H1994_029_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	029	0	1	01	01	H1994_029_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	029	0	1	01	01	H1994_029_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	029	0	1	01	01	H1994_029_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	029	0	1	01	01	H1994_029_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	029	0	1	01	01	H1994_029_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	029	0	1	01	01	H1994_029_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1113.70	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	030	0	1	01	01	H1994_030_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	030	0	1	01	01	H1994_030_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	030	0	1	01	01	H1994_030_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	030	0	1	01	01	H1994_030_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	030	0	1	01	01	H1994_030_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	030	0	1	01	01	H1994_030_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	270.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1994	030	0	1	01	01	H1994_030_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1113.70	33						1113.70	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	031	0	1	01	01	H1994_031_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	031	0	1	01	01	H1994_031_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	031	0	1	01	01	H1994_031_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1994	031	0	1	01	01	H1994_031_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H1994	031	0	1	01	01	H1994_031_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	031	0	1	01	01	H1994_031_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H1994	031	0	1	01	01	H1994_031_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1113.70	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1997	002	0	1	01	01	H1997_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1997	002	0	1	01	01	H1997_002_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					12.00	24.00	24.00					12.00	24.00	24.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	12.00	24.00	24.00	12.00	24.00	24.00				20.00		20.00
H1997	002	0	1	01	01	H1997_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H1997	002	0	1	01	01	H1997_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1997	002	0	1	01	01	H1997_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1149.44	31						1149.44	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1997	012	1	1	01	01	H1997_012_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1997	012	1	1	01	01	H1997_012_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H1997	012	1	1	01	01	H1997_012_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1997	012	1	1	01	01	H1997_012_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1997	012	1	1	01	01	H1997_012_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1038.20	28						1038.20	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H1997	012	2	1	01	01	H1997_012_2	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H1997	012	2	1	01	01	H1997_012_2	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H1997	012	2	1	01	01	H1997_012_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1997	012	2	1	01	01	H1997_012_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H1997	012	2	1	01	01	H1997_012_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1038.20	28						1038.20	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	001	0	1	04	01	H2001_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	001	0	1	04	01	H2001_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2001	001	0	1	04	01	H2001_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	001	0	1	04	01	H2001_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2001	001	0	1	04	01	H2001_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	001	0	1	04	01	H2001_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	001	0	1	04	01	H2001_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				246.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	010	0	1	04	01	H2001_010_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	010	0	1	04	01	H2001_010_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2001	010	0	1	04	01	H2001_010_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	010	0	1	04	01	H2001_010_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2001	010	0	1	04	01	H2001_010_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	010	0	1	04	01	H2001_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	010	0	1	04	01	H2001_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				152.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	017	0	1	04	01	H2001_017_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	017	0	1	04	01	H2001_017_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2001	017	0	1	04	01	H2001_017_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	017	0	1	04	01	H2001_017_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2001	017	0	1	04	01	H2001_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	017	0	1	04	01	H2001_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	017	0	1	04	01	H2001_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				520.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	018	0	1	04	01	H2001_018_0	7			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	018	0	1	04	01	H2001_018_0	7			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2001	018	0	1	04	01	H2001_018_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	018	0	1	04	01	H2001_018_0	7			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2001	018	0	1	04	01	H2001_018_0	7			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	018	0	1	04	01	H2001_018_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	018	0	1	04	01	H2001_018_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				345.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	019	0	1	04	01	H2001_019_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	019	0	1	04	01	H2001_019_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2001	019	0	1	04	01	H2001_019_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	019	0	1	04	01	H2001_019_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2001	019	0	1	04	01	H2001_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	019	0	1	04	01	H2001_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	019	0	1	04	01	H2001_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				426.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	023	0	1	04	01	H2001_023_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	023	0	1	04	01	H2001_023_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2001	023	0	1	04	01	H2001_023_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2001	023	0	1	04	01	H2001_023_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2001	023	0	1	04	01	H2001_023_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	023	0	1	04	01	H2001_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2001	023	0	1	04	01	H2001_023_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				471.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2029	001	0	1	04	01	H2029_001_0	12			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H2029	001	0	1	04	01	H2029_001_0	12			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H2029	001	0	1	04	01	H2029_001_0	12			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	25.00		75.00																									26.00		78.00				25.00		65.00				25.00				25.00		0.83				0.87	0.83	0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H2029	001	0	1	04	01	H2029_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	40.00		120.00																									40.00		120.00				40.00		110.00				40.00				40.00		1.33				1.33	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H2029	001	0	1	04	01	H2029_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H2029	001	0	1	04	01	H2029_001_0	12			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H2032	001	0	1	04	01	H2032_001_0	16			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2032	001	0	1	04	01	H2032_001_0	16			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								14.00	28.00	42.00					7.00	14.00	14.00					0.00	0.00	0.00																14.00				14.00			0.47	0.23	0.00			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00	7.00	14.00	14.00	0.00	0.00	0.00				14.00		14.00
H2032	001	0	1	04	01	H2032_001_0	16			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	94.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H2032	001	0	1	04	01	H2032_001_0	16			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	198.00					99.00	198.00	198.00																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H2032	001	0	1	04	01	H2032_001_0	16			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2032	002	0	1	04	01	H2032_002_0	16			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2032	002	0	1	04	01	H2032_002_0	16			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								14.00	28.00	42.00					7.00	14.00	14.00					0.00	0.00	0.00																14.00				14.00			0.47	0.23	0.00			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00	7.00	14.00	14.00	0.00	0.00	0.00				14.00		14.00
H2032	002	0	1	04	01	H2032_002_0	16			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	94.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H2032	002	0	1	04	01	H2032_002_0	16			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	198.00					99.00	198.00	198.00																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H2032	002	0	1	04	01	H2032_002_0	16			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2032	003	0	1	04	01	H2032_003_0	17			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2032	003	0	1	04	01	H2032_003_0	17			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								12.00	24.00	36.00					5.00	10.00	10.00					0.00	0.00	0.00																12.00				12.00			0.40	0.17	0.00			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	5.00	10.00	10.00	0.00	0.00	0.00				12.00		12.00
H2032	003	0	1	04	01	H2032_003_0	17			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								45.00	90.00	135.00					45.00	90.00	90.00					45.00	90.00	90.00																45.00				45.00			1.50	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H2032	003	0	1	04	01	H2032_003_0	17			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								95.00	190.00	285.00					95.00	190.00	190.00					95.00	190.00	190.00																95.00				95.00			3.17	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H2032	003	0	1	04	01	H2032_003_0	17			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												32							32						32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	001	0	1	02	01	H2056_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	001	0	1	02	01	H2056_001_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	001	0	1	02	01	H2056_001_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	001	0	1	02	01	H2056_001_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	001	0	1	02	01	H2056_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	001	0	1	02	01	H2056_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	001	0	1	02	01	H2056_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											785.20	33						626.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	002	0	1	02	01	H2056_002_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	002	0	1	02	01	H2056_002_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	002	0	1	02	01	H2056_002_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	002	0	1	02	01	H2056_002_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	002	0	1	02	01	H2056_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	002	0	1	02	01	H2056_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	002	0	1	02	01	H2056_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											732.31	30						581.25	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	003	0	1	02	01	H2056_003_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	003	0	1	02	01	H2056_003_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	003	0	1	02	01	H2056_003_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	003	0	1	02	01	H2056_003_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	003	0	1	02	01	H2056_003_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	003	0	1	02	01	H2056_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	003	0	1	02	01	H2056_003_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											880.68	33						755.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	004	0	1	02	01	H2056_004_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	004	0	1	02	01	H2056_004_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	004	0	1	02	01	H2056_004_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	004	0	1	02	01	H2056_004_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	004	0	1	02	01	H2056_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	004	0	1	02	01	H2056_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	004	0	1	02	01	H2056_004_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.99	30						664.46	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	005	0	1	02	01	H2056_005_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	005	0	1	02	01	H2056_005_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	005	0	1	02	01	H2056_005_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	005	0	1	02	01	H2056_005_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	005	0	1	02	01	H2056_005_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	005	0	1	02	01	H2056_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	005	0	1	02	01	H2056_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											840.44	33						780.36	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	010	0	1	02	01	H2056_010_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	010	0	1	02	01	H2056_010_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	010	0	1	02	01	H2056_010_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	010	0	1	02	01	H2056_010_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	010	0	1	02	01	H2056_010_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.85	25	25	25				78.72	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	010	0	1	02	01	H2056_010_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.52	50	50	50				28.49	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	010	0	1	02	01	H2056_010_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											912.90	33						675.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	011	0	1	02	01	H2056_011_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	011	0	1	02	01	H2056_011_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	011	0	1	02	01	H2056_011_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	011	0	1	02	01	H2056_011_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	011	0	1	02	01	H2056_011_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.19	25	25	25				95.71	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	011	0	1	02	01	H2056_011_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.95	40	40	40				41.48	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	011	0	1	02	01	H2056_011_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											640.79	27						583.19	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	012	0	1	02	01	H2056_012_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	012	0	1	02	01	H2056_012_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	012	0	1	02	01	H2056_012_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	012	0	1	02	01	H2056_012_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	012	0	1	02	01	H2056_012_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.77	25	25	25				76.43	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	012	0	1	02	01	H2056_012_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.88	50	50	50				27.06	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	012	0	1	02	01	H2056_012_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											876.99	33						656.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2056	013	0	1	02	01	H2056_013_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	013	0	1	02	01	H2056_013_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	013	0	1	02	01	H2056_013_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	013	0	1	02	01	H2056_013_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2056	013	0	1	02	01	H2056_013_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.16	25	25	25				77.35	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2056	013	0	1	02	01	H2056_013_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.72	50	50	50				26.92	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2056	013	0	1	02	01	H2056_013_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											958.63	33						661.55	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2108	022	0	1	01	01	H2108_022_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	022	0	1	01	01	H2108_022_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2108	022	0	1	01	01	H2108_022_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	022	0	1	01	01	H2108_022_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	022	0	1	01	01	H2108_022_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	022	0	1	01	01	H2108_022_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											819.19	33						487.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2108	029	0	1	01	01	H2108_029_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	029	0	1	01	01	H2108_029_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										2		2															
H2108	029	0	1	01	01	H2108_029_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	029	0	1	01	01	H2108_029_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	029	0	1	01	01	H2108_029_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	029	0	1	01	01	H2108_029_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											631.72	33						488.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2108	029	0	1	01	01	H2108_029_0	7			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					9.00	18.00	27.00											11.00	22.00	33.00				9.00	18.00	27.00				11.00				11.00			0.37	0.30		0.37	0.30	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00	22.00	33.00	9.00	18.00	27.00	11.00	22.00	33.00	9.00	18.00	27.00	11.00		11.00
H2108	030	0	1	01	01	H2108_030_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	030	0	1	01	01	H2108_030_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										2		2															
H2108	030	0	1	01	01	H2108_030_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	030	0	1	01	01	H2108_030_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	030	0	1	01	01	H2108_030_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	030	0	1	01	01	H2108_030_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											644.40	33						515.89	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2108	030	0	1	01	01	H2108_030_0	7			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					9.00	18.00	27.00											11.00	22.00	33.00				9.00	18.00	27.00				11.00				11.00			0.37	0.30		0.37	0.30	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00	22.00	33.00	9.00	18.00	27.00	11.00	22.00	33.00	9.00	18.00	27.00	11.00		11.00
H2108	036	0	1	01	01	H2108_036_0	9			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	036	0	1	01	01	H2108_036_0	9			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2108	036	0	1	01	01	H2108_036_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	036	0	1	01	01	H2108_036_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	036	0	1	01	01	H2108_036_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	036	0	1	01	01	H2108_036_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											699.54	33						488.33	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2108	040	0	1	01	01	H2108_040_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	040	0	1	01	01	H2108_040_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2108	040	0	1	01	01	H2108_040_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	040	0	1	01	01	H2108_040_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	040	0	1	01	01	H2108_040_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	040	0	1	01	01	H2108_040_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											632.96	33						531.28	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2108	042	1	1	01	01	H2108_042_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	042	1	1	01	01	H2108_042_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2108	042	1	1	01	01	H2108_042_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	042	1	1	01	01	H2108_042_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	042	1	1	01	01	H2108_042_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	042	1	1	01	01	H2108_042_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											704.71	33						502.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2108	042	2	1	01	01	H2108_042_2	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H2108	042	2	1	01	01	H2108_042_2	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2108	042	2	1	01	01	H2108_042_2	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H2108	042	2	1	01	01	H2108_042_2	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	042	2	1	01	01	H2108_042_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2108	042	2	1	01	01	H2108_042_2	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											704.71	33						502.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2117	001	0	1	04	01	H2117_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2117	001	0	1	04	01	H2117_001_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2117	001	0	1	04	01	H2117_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2117	001	0	1	04	01	H2117_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2117	001	0	1	04	01	H2117_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											71.00	50	50	50				71.00	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2117	001	0	1	04	01	H2117_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2117	001	0	1	04	01	H2117_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2117	001	0	1	04	01	H2117_001_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2128	002	0	1	04	01	H2128_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2128	002	0	1	04	01	H2128_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2128	002	0	1	04	01	H2128_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2128	002	0	1	04	01	H2128_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.74	43	43	43				99.74	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2128	002	0	1	04	01	H2128_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2128	002	0	1	04	01	H2128_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2128	004	0	1	04	01	H2128_004_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2128	004	0	1	04	01	H2128_004_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2128	004	0	1	04	01	H2128_004_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2128	004	0	1	04	01	H2128_004_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.94	49	49	49				98.94	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2128	004	0	1	04	01	H2128_004_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2128	004	0	1	04	01	H2128_004_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2128	004	0	1	04	01	H2128_004_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2134	005	0	1	01	01	H2134_005_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2134	005	0	1	01	01	H2134_005_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					9.00	18.00	27.00											20.00	40.00	60.00				9.00	18.00	0.00				20.00				20.00			0.67	0.30		0.67	0.30	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2134	005	0	1	01	01	H2134_005_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2134	005	0	1	01	01	H2134_005_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											93.16	50	50	50				93.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2134	005	0	1	01	01	H2134_005_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2134	005	0	1	01	01	H2134_005_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2162	001	0	1	01	01	H2162_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2162	001	0	1	01	01	H2162_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2162	001	0	1	01	01	H2162_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2162	001	0	1	01	01	H2162_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.50	49	49	49				99.50	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2162	001	0	1	01	01	H2162_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2162	001	0	1	01	01	H2162_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2168	001	0	1	01	01	H2168_001_0	11		N	Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	90				2	2			90					10	31	5.00	10.00	15.00																					15.00																	5.00			5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00						15.00				5.00		5.00
H2168	001	0	1	01	01	H2168_001_0	11		N	Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90					10	31	11.00	22.00	33.00																					33.00																	11.00			11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00						33.00				11.00		11.00
H2168	001	0	1	01	01	H2168_001_0	11		N	Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90					10	31				99.01	21	21	21																				21																21		21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	001	0	1	01	01	H2168_001_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90					10	31				98.78	37	37	37																				37																37		37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	001	0	1	01	01	H2168_001_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30															10	31				549.55	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H2168	002	0	1	01	01	H2168_002_0	10		N	Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	90				2	2			90					10	31	6.00	12.00	18.00																					18.00																	6.00			6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00						18.00				6.00		6.00
H2168	002	0	1	01	01	H2168_002_0	10		N	Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90					10	31	12.00	24.00	36.00																					36.00																	12.00			12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00						36.00				12.00		12.00
H2168	002	0	1	01	01	H2168_002_0	10		N	Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90					10	31				114.48	24	24	24																				24																24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	002	0	1	01	01	H2168_002_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90					10	31				97.76	33	33	33																				33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	002	0	1	01	01	H2168_002_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30															10	31				654.40	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H2168	003	0	1	01	01	H2168_003_0	11		N	Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	90				2	2			90					10	31	5.00	10.00	15.00																					15.00																	5.00			5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00						15.00				5.00		5.00
H2168	003	0	1	01	01	H2168_003_0	11		N	Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90					10	31	11.00	22.00	33.00																					33.00																	11.00			11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00						33.00				11.00		11.00
H2168	003	0	1	01	01	H2168_003_0	11		N	Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90					10	31				91.42	19	19	19																				19																19		19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	003	0	1	01	01	H2168_003_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90					10	31				91.22	40	40	40																				40																40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	003	0	1	01	01	H2168_003_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30															10	31				596.56	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H2168	004	0	1	01	01	H2168_004_0	9			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	90				2	2			90					10	31	6.00	12.00	18.00																					18.00																	6.00			6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00						18.00				6.00		6.00
H2168	004	0	1	01	01	H2168_004_0	9			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90					10	31	11.00	22.00	33.00																					33.00																	11.00			11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00						33.00				11.00		11.00
H2168	004	0	1	01	01	H2168_004_0	9			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90					10	31				136.14	23	23	23																				23																23		23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	004	0	1	01	01	H2168_004_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90					10	31				97.82	33	33	33																				33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2168	004	0	1	01	01	H2168_004_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30															10	31				796.51	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H2171	001	0	1	01	01	H2171_001_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2171	001	0	1	01	01	H2171_001_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2171	001	0	1	01	01	H2171_001_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2171	001	0	1	01	01	H2171_001_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2171	001	0	1	01	01	H2171_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H2171	001	0	1	01	01	H2171_001_0	11			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2171	001	0	1	01	01	H2171_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2171	001	0	1	01	01	H2171_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2171	003	0	1	01	01	H2171_003_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2171	003	0	1	01	01	H2171_003_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2171	003	0	1	01	01	H2171_003_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2171	003	0	1	01	01	H2171_003_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2171	003	0	1	01	01	H2171_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	80.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H2171	003	0	1	01	01	H2171_003_0	11			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	80.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2171	003	0	1	01	01	H2171_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2171	003	0	1	01	01	H2171_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2172	001	0	1	02	01	H2172_001_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	001	0	1	02	01	H2172_001_0	9			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	001	0	1	02	01	H2172_001_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	001	0	1	02	01	H2172_001_0	9			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	001	0	1	02	01	H2172_001_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.56	1.40	1.40			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00				35.00		35.00
H2172	001	0	1	02	01	H2172_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	160.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	001	0	1	02	01	H2172_001_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	001	0	1	02	01	H2172_001_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	001	0	1	02	01	H2172_001_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	002	0	1	02	01	H2172_002_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	002	0	1	02	01	H2172_002_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	002	0	1	02	01	H2172_002_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	002	0	1	02	01	H2172_002_0	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	002	0	1	02	01	H2172_002_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.56	1.40	1.40			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00				35.00		35.00
H2172	002	0	1	02	01	H2172_002_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	160.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	002	0	1	02	01	H2172_002_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	002	0	1	02	01	H2172_002_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	002	0	1	02	01	H2172_002_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	003	0	1	02	01	H2172_003_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	003	0	1	02	01	H2172_003_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	003	0	1	02	01	H2172_003_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	003	0	1	02	01	H2172_003_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	003	0	1	02	01	H2172_003_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	003	0	1	02	01	H2172_003_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	003	0	1	02	01	H2172_003_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	004	0	1	02	01	H2172_004_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	004	0	1	02	01	H2172_004_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	004	0	1	02	01	H2172_004_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	004	0	1	02	01	H2172_004_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	004	0	1	02	01	H2172_004_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	004	0	1	02	01	H2172_004_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	004	0	1	02	01	H2172_004_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	006	0	1	01	01	H2172_006_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					5.00	10.00	15.00					5.00	0.00	0.00																10.00				10.00			0.33	0.16	0.16			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	5.00	10.00	15.00	5.00	0.00	0.00				10.00		10.00
H2172	006	0	1	01	01	H2172_006_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					15.00	30.00	45.00					15.00	0.00	0.00																20.00				20.00			0.66	0.50	0.50			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	15.00	30.00	45.00	15.00	0.00	0.00				20.00		20.00
H2172	006	0	1	01	01	H2172_006_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	006	0	1	01	01	H2172_006_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	006	0	1	01	01	H2172_006_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	006	0	1	01	01	H2172_006_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	006	0	1	01	01	H2172_006_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	008	0	1	02	01	H2172_008_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	008	0	1	02	01	H2172_008_0	9			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	008	0	1	02	01	H2172_008_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.66	0.33	0.33			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00
H2172	008	0	1	02	01	H2172_008_0	9			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.66	0.33	0.33			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	008	0	1	02	01	H2172_008_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.56	1.40	1.40			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00				35.00		35.00
H2172	008	0	1	02	01	H2172_008_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					80.00	160.00	240.00					80.00	160.00	160.00																100.00				100.00			3.33	2.66	2.66			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	008	0	1	02	01	H2172_008_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	008	0	1	02	01	H2172_008_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	008	0	1	02	01	H2172_008_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	009	0	1	02	01	H2172_009_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	009	0	1	02	01	H2172_009_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.66	0.33	0.33			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00
H2172	009	0	1	02	01	H2172_009_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	009	0	1	02	01	H2172_009_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	009	0	1	02	01	H2172_009_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	009	0	1	02	01	H2172_009_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	009	0	1	02	01	H2172_009_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	010	0	1	02	01	H2172_010_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	010	0	1	02	01	H2172_010_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	010	0	1	02	01	H2172_010_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	010	0	1	02	01	H2172_010_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	010	0	1	02	01	H2172_010_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	010	0	1	02	01	H2172_010_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	010	0	1	02	01	H2172_010_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	011	0	1	01	01	H2172_011_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					5.00	10.00	15.00					5.00	0.00	0.00																10.00				10.00			0.33	0.16	0.16			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	5.00	10.00	15.00	5.00	0.00	0.00				10.00		10.00
H2172	011	0	1	01	01	H2172_011_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					15.00	30.00	45.00					15.00	0.00	0.00																20.00				20.00			0.66	0.50	0.50			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	15.00	30.00	45.00	15.00	0.00	0.00				20.00		20.00
H2172	011	0	1	01	01	H2172_011_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	011	0	1	01	01	H2172_011_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	011	0	1	01	01	H2172_011_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	011	0	1	01	01	H2172_011_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	011	0	1	01	01	H2172_011_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	012	0	1	02	01	H2172_012_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H2172	012	0	1	02	01	H2172_012_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	012	0	1	02	01	H2172_012_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	012	0	1	02	01	H2172_012_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	012	0	1	02	01	H2172_012_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	012	0	1	02	01	H2172_012_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	012	0	1	02	01	H2172_012_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2172	013	0	1	02	01	H2172_013_0	9			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					3.00	6.00	9.00					3.00	0.00	0.00																10.00				10.00			0.33	0.10	0.10			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	3.00	6.00	9.00	0.00	0.00	0.00				10.00		10.00
H2172	013	0	1	02	01	H2172_013_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.66	0.40	0.40			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00
H2172	013	0	1	02	01	H2172_013_0	9			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00
H2172	013	0	1	02	01	H2172_013_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	013	0	1	02	01	H2172_013_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2172	013	0	1	02	01	H2172_013_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2172	013	0	1	02	01	H2172_013_0	9			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2185	003	0	1	02	01	H2185_003_0	8			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				1	2								10	31	2.00	4.00	6.00																																						2.00			2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2185	003	0	1	02	01	H2185_003_0	8			Generic	4	01	1	2	2	1	111		10			1	30	60	90				1	2								10	31	15.00	30.00	45.00																																						15.00			15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2185	003	0	1	02	01	H2185_003_0	8			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				1	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00										35.00		35.00
H2185	003	0	1	02	01	H2185_003_0	8			Non-Preferred Brand	4	10	1	2	4	1	111		10			1	30	60	90				1	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2185	003	0	1	02	01	H2185_003_0	8			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				797.12	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2225	001	0	1	01	01	H2225_001_0	9		N	Preferred Generic	2	01	1	1	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2225	001	0	1	01	01	H2225_001_0	9		N	Generic	2	01	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2225	001	0	1	01	01	H2225_001_0	9		N	Preferred Brand	2	10	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2225	001	0	1	01	01	H2225_001_0	9		N	Non-Preferred Brand	2	11	1	1	4	1	111		01	111		1	31	60	100				2	2	31	60	100				31		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2225	001	0	1	01	01	H2225_001_0	9		N	Specialty Tier	2	11	1	1	5	1	010		01	010		1	31								31						31		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2230	002	0	1	04	01	H2230_002_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	6.00		6.00
H2230	002	0	1	04	01	H2230_002_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	15.00	15.00				5.00	10.00	10.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00	10.00	15.00	15.00	5.00	10.00	10.00	10.00		10.00
H2230	002	0	1	04	01	H2230_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	002	0	1	04	01	H2230_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	002	0	1	04	01	H2230_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2230	017	0	1	04	01	H2230_017_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.17	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	10.00		10.00
H2230	017	0	1	04	01	H2230_017_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											15.00	25.00	25.00				10.00	20.00	20.00				20.00				20.00			0.67	0.33		0.50	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	15.00	25.00	25.00	10.00	20.00	20.00	20.00		20.00
H2230	017	0	1	04	01	H2230_017_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	017	0	1	04	01	H2230_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	017	0	1	04	01	H2230_017_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2230	018	1	1	04	01	H2230_018_1	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.17	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	8.00		8.00
H2230	018	1	1	04	01	H2230_018_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					6.00	12.00	18.00											11.00	17.00	17.00				6.00	12.00	12.00				12.00				12.00			0.40	0.20		0.37	0.20	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	6.00	12.00	18.00	11.00	17.00	17.00	6.00	12.00	12.00	12.00		12.00
H2230	018	1	1	04	01	H2230_018_1	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	018	1	1	04	01	H2230_018_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	018	1	1	04	01	H2230_018_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2230	018	2	1	04	01	H2230_018_2	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.17	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	8.00		8.00
H2230	018	2	1	04	01	H2230_018_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					6.00	12.00	18.00											11.00	17.00	17.00				6.00	12.00	12.00				12.00				12.00			0.40	0.20		0.37	0.20	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	6.00	12.00	18.00	11.00	17.00	17.00	6.00	12.00	12.00	12.00		12.00
H2230	018	2	1	04	01	H2230_018_2	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	018	2	1	04	01	H2230_018_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2230	018	2	1	04	01	H2230_018_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2235	001	0	1	01	01	H2235_001_0	15			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	001	0	1	01	01	H2235_001_0	15			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	3.00	6.00	9.00																					0.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													3.00	6.00	9.00						0.00				3.00		3.00
H2235	001	0	1	01	01	H2235_001_0	15			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	35.00	70.00	105.00																					95.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						95.00				35.00		35.00
H2235	001	0	1	01	01	H2235_001_0	15			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	85.00	170.00	255.00																					245.00																85.00				85.00		2.83						2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	001	0	1	01	01	H2235_001_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				742.60	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	002	0	1	01	01	H2235_002_0	15			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	002	0	1	01	01	H2235_002_0	15			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					0.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00						0.00				10.00		10.00
H2235	002	0	1	01	01	H2235_002_0	15			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2235	002	0	1	01	01	H2235_002_0	15			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	002	0	1	01	01	H2235_002_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1114.16	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	003	0	1	01	01	H2235_003_0	15			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	003	0	1	01	01	H2235_003_0	15			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H2235	003	0	1	01	01	H2235_003_0	15			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	30.00	60.00	90.00																					80.00																30.00				30.00		1.00						0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													30.00	60.00	90.00						80.00				30.00		30.00
H2235	003	0	1	01	01	H2235_003_0	15			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	85.00	170.00	255.00																					245.00																85.00				85.00		2.83						2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	003	0	1	01	01	H2235_003_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				744.46	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	005	0	1	01	01	H2235_005_0	15			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	005	0	1	01	01	H2235_005_0	15			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					0.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00						0.00				10.00		10.00
H2235	005	0	1	01	01	H2235_005_0	15			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2235	005	0	1	01	01	H2235_005_0	15			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	005	0	1	01	01	H2235_005_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1114.16	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	006	0	1	02	01	H2235_006_0	15			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	006	0	1	02	01	H2235_006_0	15			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	3.00	6.00	9.00																					0.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													3.00	6.00	9.00						0.00				3.00		3.00
H2235	006	0	1	02	01	H2235_006_0	15			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	35.00	70.00	105.00																					95.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						95.00				35.00		35.00
H2235	006	0	1	02	01	H2235_006_0	15			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	85.00	170.00	255.00																					245.00																85.00				85.00		2.83						2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2235	006	0	1	02	01	H2235_006_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				710.52	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H2246	018	0	1	04	01	H2246_018_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	018	0	1	04	01	H2246_018_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	018	0	1	04	01	H2246_018_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	018	0	1	04	01	H2246_018_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	018	0	1	04	01	H2246_018_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	018	0	1	04	01	H2246_018_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	018	0	1	04	01	H2246_018_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				451.33	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	019	0	1	04	01	H2246_019_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	019	0	1	04	01	H2246_019_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2246	019	0	1	04	01	H2246_019_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	24.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	019	0	1	04	01	H2246_019_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	24.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	019	0	1	04	01	H2246_019_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	019	0	1	04	01	H2246_019_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	019	0	1	04	01	H2246_019_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				451.33	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	026	0	1	04	01	H2246_026_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	026	0	1	04	01	H2246_026_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	026	0	1	04	01	H2246_026_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	026	0	1	04	01	H2246_026_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	026	0	1	04	01	H2246_026_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	026	0	1	04	01	H2246_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	026	0	1	04	01	H2246_026_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				991.59	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	032	0	1	04	01	H2246_032_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	032	0	1	04	01	H2246_032_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	032	0	1	04	01	H2246_032_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2246	032	0	1	04	01	H2246_032_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H2246	032	0	1	04	01	H2246_032_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	032	0	1	04	01	H2246_032_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2246	032	0	1	04	01	H2246_032_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				451.33	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2256	001	1	1	01	01	H2256_001_1	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													2.00	4.00	6.00				2.00	4.00	4.00				2.00		2.00
H2256	001	1	1	01	01	H2256_001_1	7			Preferred Generic	4	01	3	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1		3															
H2256	001	1	1	01	01	H2256_001_1	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	001	1	1	01	01	H2256_001_1	7			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1		3															
H2256	001	1	1	01	01	H2256_001_1	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	30.00	60.00	90.00																			30.00	60.00	60.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													30.00	60.00	90.00				30.00	60.00	60.00				30.00		30.00
H2256	001	1	1	01	01	H2256_001_1	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	80.00	160.00	240.00																			80.00	160.00	240.00																80.00				80.00		2.67			2.67			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	001	1	1	01	01	H2256_001_1	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	001	1	1	01	01	H2256_001_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	001	1	1	01	01	H2256_001_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	001	2	1	01	01	H2256_001_2	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													2.00	4.00	6.00				2.00	4.00	4.00				2.00		2.00
H2256	001	2	1	01	01	H2256_001_2	7			Preferred Generic	4	01	3	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1		3															
H2256	001	2	1	01	01	H2256_001_2	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	001	2	1	01	01	H2256_001_2	7			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1		3															
H2256	001	2	1	01	01	H2256_001_2	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	30.00	60.00	90.00																			30.00	60.00	60.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													30.00	60.00	90.00				30.00	60.00	60.00				30.00		30.00
H2256	001	2	1	01	01	H2256_001_2	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	80.00	160.00	240.00																			80.00	160.00	240.00																80.00				80.00		2.67			2.67			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	001	2	1	01	01	H2256_001_2	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	001	2	1	01	01	H2256_001_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	001	2	1	01	01	H2256_001_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	001	6	1	01	01	H2256_001_6	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													2.00	4.00	6.00				2.00	4.00	4.00				2.00		2.00
H2256	001	6	1	01	01	H2256_001_6	7			Preferred Generic	4	01	3	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1		3															
H2256	001	6	1	01	01	H2256_001_6	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	001	6	1	01	01	H2256_001_6	7			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1		3															
H2256	001	6	1	01	01	H2256_001_6	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	30.00	60.00	90.00																			30.00	60.00	60.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													30.00	60.00	90.00				30.00	60.00	60.00				30.00		30.00
H2256	001	6	1	01	01	H2256_001_6	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	80.00	160.00	240.00																			80.00	160.00	240.00																80.00				80.00		2.67			2.67			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	001	6	1	01	01	H2256_001_6	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	001	6	1	01	01	H2256_001_6	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	001	6	1	01	01	H2256_001_6	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	015	1	1	01	01	H2256_015_1	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	015	1	1	01	01	H2256_015_1	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													8.00	16.00	24.00				8.00	16.00	16.00				8.00		8.00
H2256	015	1	1	01	01	H2256_015_1	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2256	015	1	1	01	01	H2256_015_1	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	015	1	1	01	01	H2256_015_1	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	015	1	1	01	01	H2256_015_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	015	1	1	01	01	H2256_015_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	015	2	1	01	01	H2256_015_2	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	015	2	1	01	01	H2256_015_2	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													8.00	16.00	24.00				8.00	16.00	16.00				8.00		8.00
H2256	015	2	1	01	01	H2256_015_2	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2256	015	2	1	01	01	H2256_015_2	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	015	2	1	01	01	H2256_015_2	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	015	2	1	01	01	H2256_015_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	015	2	1	01	01	H2256_015_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	015	6	1	01	01	H2256_015_6	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	015	6	1	01	01	H2256_015_6	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													8.00	16.00	24.00				8.00	16.00	16.00				8.00		8.00
H2256	015	6	1	01	01	H2256_015_6	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2256	015	6	1	01	01	H2256_015_6	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	015	6	1	01	01	H2256_015_6	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	015	6	1	01	01	H2256_015_6	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	015	6	1	01	01	H2256_015_6	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	018	1	1	01	01	H2256_018_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	018	1	1	01	01	H2256_018_1	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	018	1	1	01	01	H2256_018_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	018	1	1	01	01	H2256_018_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	018	1	1	01	01	H2256_018_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	018	1	1	01	01	H2256_018_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	018	1	1	01	01	H2256_018_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	018	7	1	01	01	H2256_018_7	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	018	7	1	01	01	H2256_018_7	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	018	7	1	01	01	H2256_018_7	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	018	7	1	01	01	H2256_018_7	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	018	7	1	01	01	H2256_018_7	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	018	7	1	01	01	H2256_018_7	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	018	7	1	01	01	H2256_018_7	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	018	8	1	01	01	H2256_018_8	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	018	8	1	01	01	H2256_018_8	6			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	018	8	1	01	01	H2256_018_8	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	018	8	1	01	01	H2256_018_8	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	018	8	1	01	01	H2256_018_8	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	018	8	1	01	01	H2256_018_8	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	018	8	1	01	01	H2256_018_8	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	026	1	1	01	01	H2256_026_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	026	1	1	01	01	H2256_026_1	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	026	1	1	01	01	H2256_026_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	026	1	1	01	01	H2256_026_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	026	1	1	01	01	H2256_026_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	026	1	1	01	01	H2256_026_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	026	1	1	01	01	H2256_026_1	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	026	2	1	01	01	H2256_026_2	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	026	2	1	01	01	H2256_026_2	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	026	2	1	01	01	H2256_026_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	026	2	1	01	01	H2256_026_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	026	2	1	01	01	H2256_026_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	026	2	1	01	01	H2256_026_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	026	2	1	01	01	H2256_026_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	026	3	1	01	01	H2256_026_3	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	026	3	1	01	01	H2256_026_3	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	026	3	1	01	01	H2256_026_3	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	026	3	1	01	01	H2256_026_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	026	3	1	01	01	H2256_026_3	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	026	3	1	01	01	H2256_026_3	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	026	3	1	01	01	H2256_026_3	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	028	0	1	01	01	H2256_028_0	5			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	028	0	1	01	01	H2256_028_0	5			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	028	0	1	01	01	H2256_028_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	028	0	1	01	01	H2256_028_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	028	0	1	01	01	H2256_028_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	028	0	1	01	01	H2256_028_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	028	0	1	01	01	H2256_028_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	033	0	1	01	01	H2256_033_0	7			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00
H2256	033	0	1	01	01	H2256_033_0	7			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													8.00	16.00	24.00				8.00	16.00	16.00				8.00		8.00
H2256	033	0	1	01	01	H2256_033_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2256	033	0	1	01	01	H2256_033_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2256	033	0	1	01	01	H2256_033_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	033	0	1	01	01	H2256_033_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	033	0	1	01	01	H2256_033_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	000		1	30	60	90				1	2							30		31	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	034	0	1	01	01	H2256_034_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	034	0	1	01	01	H2256_034_0	8			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	034	0	1	01	01	H2256_034_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	034	0	1	01	01	H2256_034_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	034	0	1	01	01	H2256_034_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	034	0	1	01	01	H2256_034_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	034	0	1	01	01	H2256_034_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	036	0	1	01	01	H2256_036_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	036	0	1	01	01	H2256_036_0	8			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H2256	036	0	1	01	01	H2256_036_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	036	0	1	01	01	H2256_036_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	036	0	1	01	01	H2256_036_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	036	0	1	01	01	H2256_036_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	036	0	1	01	01	H2256_036_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2256	046	0	1	01	01	H2256_046_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H2256	046	0	1	01	01	H2256_046_0	8			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					2.00	4.00	6.00					2.00	4.00	4.00																19.00				2.00			0.63	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	2.00	4.00	6.00	2.00	4.00	4.00				19.00		2.00
H2256	046	0	1	01	01	H2256_046_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2256	046	0	1	01	01	H2256_046_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2256	046	0	1	01	01	H2256_046_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	046	0	1	01	01	H2256_046_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H2256	046	0	1	01	01	H2256_046_0	8			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H2261	005	0	1	01	01	H2261_005_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	6.00		6.00
H2261	005	0	1	01	01	H2261_005_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	15.00	15.00				5.00	10.00	10.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00	10.00	15.00	15.00	5.00	10.00	10.00	10.00		10.00
H2261	005	0	1	01	01	H2261_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	005	0	1	01	01	H2261_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	005	0	1	01	01	H2261_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2261	022	1	1	01	01	H2261_022_1	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.17	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	8.00		8.00
H2261	022	1	1	01	01	H2261_022_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					6.00	12.00	18.00											11.00	17.00	17.00				6.00	12.00	12.00				12.00				12.00			0.40	0.20		0.37	0.20	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	6.00	12.00	18.00	11.00	17.00	17.00	6.00	12.00	12.00	12.00		12.00
H2261	022	1	1	01	01	H2261_022_1	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	022	1	1	01	01	H2261_022_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	022	1	1	01	01	H2261_022_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2261	022	2	1	01	01	H2261_022_2	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.17	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	8.00		8.00
H2261	022	2	1	01	01	H2261_022_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					6.00	12.00	18.00											11.00	17.00	17.00				6.00	12.00	12.00				12.00				12.00			0.40	0.20		0.37	0.20	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	6.00	12.00	18.00	11.00	17.00	17.00	6.00	12.00	12.00	12.00		12.00
H2261	022	2	1	01	01	H2261_022_2	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	022	2	1	01	01	H2261_022_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	022	2	1	01	01	H2261_022_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2261	023	1	1	02	01	H2261_023_1	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	6.00		6.00
H2261	023	1	1	02	01	H2261_023_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	15.00	15.00				5.00	10.00	10.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00	10.00	15.00	15.00	5.00	10.00	10.00	10.00		10.00
H2261	023	1	1	02	01	H2261_023_1	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	023	1	1	02	01	H2261_023_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	023	1	1	02	01	H2261_023_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2261	023	2	1	02	01	H2261_023_2	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	6.00		6.00
H2261	023	2	1	02	01	H2261_023_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	15.00	15.00				5.00	10.00	10.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00	10.00	15.00	15.00	5.00	10.00	10.00	10.00		10.00
H2261	023	2	1	02	01	H2261_023_2	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	023	2	1	02	01	H2261_023_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	023	2	1	02	01	H2261_023_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2261	024	0	1	01	01	H2261_024_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											5.00	5.00	5.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.17	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	5.00	5.00	5.00	0.00	0.00	0.00	8.00		8.00
H2261	024	0	1	01	01	H2261_024_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											13.00	21.00	21.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.43	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	13.00	21.00	21.00	8.00	16.00	16.00	20.00		20.00
H2261	024	0	1	01	01	H2261_024_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	89.00	89.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	024	0	1	01	01	H2261_024_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	195.00	195.00				95.00	190.00	190.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2261	024	0	1	01	01	H2261_024_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2292	003	0	1	04	01	H2292_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2292	003	0	1	04	01	H2292_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2292	003	0	1	04	01	H2292_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2292	003	0	1	04	01	H2292_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2292	003	0	1	04	01	H2292_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2292	003	0	1	04	01	H2292_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	001	0	1	04	01	H2293_001_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	001	0	1	04	01	H2293_001_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	001	0	1	04	01	H2293_001_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	001	0	1	04	01	H2293_001_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	001	0	1	04	01	H2293_001_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	001	0	1	04	01	H2293_001_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	001	0	1	04	01	H2293_001_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.55	28						626.98	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	006	0	1	04	01	H2293_006_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	006	0	1	04	01	H2293_006_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	006	0	1	04	01	H2293_006_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	006	0	1	04	01	H2293_006_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	006	0	1	04	01	H2293_006_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	006	0	1	04	01	H2293_006_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	006	0	1	04	01	H2293_006_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											886.42	33						658.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	007	0	1	04	01	H2293_007_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	007	0	1	04	01	H2293_007_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	007	0	1	04	01	H2293_007_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	007	0	1	04	01	H2293_007_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	007	0	1	04	01	H2293_007_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	007	0	1	04	01	H2293_007_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	007	0	1	04	01	H2293_007_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											885.61	33						657.22	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	008	0	1	04	01	H2293_008_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	008	0	1	04	01	H2293_008_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	008	0	1	04	01	H2293_008_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	008	0	1	04	01	H2293_008_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	008	0	1	04	01	H2293_008_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	008	0	1	04	01	H2293_008_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	008	0	1	04	01	H2293_008_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											885.63	33						657.24	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	010	0	1	04	01	H2293_010_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	010	0	1	04	01	H2293_010_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	010	0	1	04	01	H2293_010_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	010	0	1	04	01	H2293_010_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	010	0	1	04	01	H2293_010_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											110.18	25	25	25				99.67	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	010	0	1	04	01	H2293_010_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.88	40	40	40				41.51	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	010	0	1	04	01	H2293_010_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											770.96	27						553.46	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	011	0	1	04	01	H2293_011_0	5			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	011	0	1	04	01	H2293_011_0	5			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	011	0	1	04	01	H2293_011_0	5			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	011	0	1	04	01	H2293_011_0	5			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	011	0	1	04	01	H2293_011_0	5			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	011	0	1	04	01	H2293_011_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	011	0	1	04	01	H2293_011_0	5			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											655.04	28						623.94	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	013	0	1	04	01	H2293_013_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	013	0	1	04	01	H2293_013_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	013	0	1	04	01	H2293_013_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	013	0	1	04	01	H2293_013_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	013	0	1	04	01	H2293_013_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	013	0	1	04	01	H2293_013_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	013	0	1	04	01	H2293_013_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											793.82	30						591.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	014	0	1	04	01	H2293_014_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	014	0	1	04	01	H2293_014_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	014	0	1	04	01	H2293_014_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	014	0	1	04	01	H2293_014_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	014	0	1	04	01	H2293_014_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	014	0	1	04	01	H2293_014_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	014	0	1	04	01	H2293_014_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											762.81	30						573.49	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	016	0	1	04	01	H2293_016_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	016	0	1	04	01	H2293_016_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	016	0	1	04	01	H2293_016_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	016	0	1	04	01	H2293_016_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	016	0	1	04	01	H2293_016_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	016	0	1	04	01	H2293_016_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	016	0	1	04	01	H2293_016_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.31	30						587.75	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	017	0	1	04	01	H2293_017_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	017	0	1	04	01	H2293_017_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	017	0	1	04	01	H2293_017_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	017	0	1	04	01	H2293_017_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	017	0	1	04	01	H2293_017_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	017	0	1	04	01	H2293_017_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	017	0	1	04	01	H2293_017_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.79	30						590.05	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	018	0	1	04	01	H2293_018_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	018	0	1	04	01	H2293_018_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	018	0	1	04	01	H2293_018_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	018	0	1	04	01	H2293_018_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	018	0	1	04	01	H2293_018_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	018	0	1	04	01	H2293_018_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	018	0	1	04	01	H2293_018_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.37	28						556.03	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	019	0	1	04	01	H2293_019_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	019	0	1	04	01	H2293_019_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	019	0	1	04	01	H2293_019_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	019	0	1	04	01	H2293_019_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	019	0	1	04	01	H2293_019_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	019	0	1	04	01	H2293_019_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	019	0	1	04	01	H2293_019_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											792.84	30						589.83	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2293	023	0	1	04	01	H2293_023_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	023	0	1	04	01	H2293_023_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	023	0	1	04	01	H2293_023_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	023	0	1	04	01	H2293_023_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2293	023	0	1	04	01	H2293_023_0	4			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2293	023	0	1	04	01	H2293_023_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2293	023	0	1	04	01	H2293_023_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											661.48	28						621.48	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	022	1	1	02	01	H2320_022_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	0.00											10.00	20.00	30.00				4.00	8.00	0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	022	1	1	02	01	H2320_022_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H2320	022	1	1	02	01	H2320_022_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	1	1	02	01	H2320_022_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.85	50	50	50				30.09	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	1	1	02	01	H2320_022_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	022	2	1	02	01	H2320_022_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	0.00											10.00	20.00	30.00				4.00	8.00	0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	022	2	1	02	01	H2320_022_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H2320	022	2	1	02	01	H2320_022_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	2	1	02	01	H2320_022_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.85	50	50	50				30.09	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	2	1	02	01	H2320_022_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	022	3	1	02	01	H2320_022_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	0.00											10.00	20.00	30.00				4.00	8.00	0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	022	3	1	02	01	H2320_022_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H2320	022	3	1	02	01	H2320_022_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	3	1	02	01	H2320_022_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.85	50	50	50				30.09	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	3	1	02	01	H2320_022_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	022	4	1	02	01	H2320_022_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	0.00											10.00	20.00	30.00				4.00	8.00	0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	022	4	1	02	01	H2320_022_4	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H2320	022	4	1	02	01	H2320_022_4	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	4	1	02	01	H2320_022_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.85	50	50	50				30.09	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	4	1	02	01	H2320_022_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	022	5	1	02	01	H2320_022_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	0.00											10.00	20.00	30.00				4.00	8.00	0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	022	5	1	02	01	H2320_022_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H2320	022	5	1	02	01	H2320_022_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	5	1	02	01	H2320_022_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.85	50	50	50				30.09	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	022	5	1	02	01	H2320_022_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	028	1	1	02	01	H2320_028_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	028	1	1	02	01	H2320_028_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					8.00	16.00	24.00											13.00	26.00	39.00				8.00	16.00	0.00				13.00				13.00			0.43	0.27		0.43	0.27	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	8.00	16.00	24.00	13.00	26.00	39.00	8.00	16.00	0.00	13.00		13.00
H2320	028	1	1	02	01	H2320_028_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								43.00	86.00	129.00					38.00	76.00	114.00											43.00	86.00	129.00				38.00	76.00	95.00				43.00				43.00			1.43	1.27		1.43	1.27	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H2320	028	1	1	02	01	H2320_028_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.67	45	45	45				25.93	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	028	1	1	02	01	H2320_028_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	028	2	1	02	01	H2320_028_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	028	2	1	02	01	H2320_028_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					8.00	16.00	24.00											13.00	26.00	39.00				8.00	16.00	0.00				13.00				13.00			0.43	0.27		0.43	0.27	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	8.00	16.00	24.00	13.00	26.00	39.00	8.00	16.00	0.00	13.00		13.00
H2320	028	2	1	02	01	H2320_028_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								43.00	86.00	129.00					38.00	76.00	114.00											43.00	86.00	129.00				38.00	76.00	95.00				43.00				43.00			1.43	1.27		1.43	1.27	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H2320	028	2	1	02	01	H2320_028_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.67	45	45	45				25.93	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	028	2	1	02	01	H2320_028_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	028	3	1	02	01	H2320_028_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	028	3	1	02	01	H2320_028_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					8.00	16.00	24.00											13.00	26.00	39.00				8.00	16.00	0.00				13.00				13.00			0.43	0.27		0.43	0.27	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	8.00	16.00	24.00	13.00	26.00	39.00	8.00	16.00	0.00	13.00		13.00
H2320	028	3	1	02	01	H2320_028_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								43.00	86.00	129.00					38.00	76.00	114.00											43.00	86.00	129.00				38.00	76.00	95.00				43.00				43.00			1.43	1.27		1.43	1.27	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H2320	028	3	1	02	01	H2320_028_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.67	45	45	45				25.93	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	028	3	1	02	01	H2320_028_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	028	4	1	02	01	H2320_028_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	028	4	1	02	01	H2320_028_4	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					8.00	16.00	24.00											13.00	26.00	39.00				8.00	16.00	0.00				13.00				13.00			0.43	0.27		0.43	0.27	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	8.00	16.00	24.00	13.00	26.00	39.00	8.00	16.00	0.00	13.00		13.00
H2320	028	4	1	02	01	H2320_028_4	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								43.00	86.00	129.00					38.00	76.00	114.00											43.00	86.00	129.00				38.00	76.00	95.00				43.00				43.00			1.43	1.27		1.43	1.27	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H2320	028	4	1	02	01	H2320_028_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.67	45	45	45				25.93	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	028	4	1	02	01	H2320_028_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	028	5	1	02	01	H2320_028_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	028	5	1	02	01	H2320_028_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					8.00	16.00	24.00											13.00	26.00	39.00				8.00	16.00	0.00				13.00				13.00			0.43	0.27		0.43	0.27	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	8.00	16.00	24.00	13.00	26.00	39.00	8.00	16.00	0.00	13.00		13.00
H2320	028	5	1	02	01	H2320_028_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								43.00	86.00	129.00					38.00	76.00	114.00											43.00	86.00	129.00				38.00	76.00	95.00				43.00				43.00			1.43	1.27		1.43	1.27	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H2320	028	5	1	02	01	H2320_028_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.67	45	45	45				25.93	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	028	5	1	02	01	H2320_028_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	029	1	1	02	01	H2320_029_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	029	1	1	02	01	H2320_029_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H2320	029	1	1	02	01	H2320_029_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	1	1	02	01	H2320_029_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.71	50	50	50				50.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	1	1	02	01	H2320_029_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	029	2	1	02	01	H2320_029_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	029	2	1	02	01	H2320_029_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H2320	029	2	1	02	01	H2320_029_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	2	1	02	01	H2320_029_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.71	50	50	50				50.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	2	1	02	01	H2320_029_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	029	3	1	02	01	H2320_029_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	029	3	1	02	01	H2320_029_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H2320	029	3	1	02	01	H2320_029_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	3	1	02	01	H2320_029_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.71	50	50	50				50.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	3	1	02	01	H2320_029_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	029	4	1	02	01	H2320_029_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	029	4	1	02	01	H2320_029_4	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H2320	029	4	1	02	01	H2320_029_4	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	4	1	02	01	H2320_029_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.71	50	50	50				50.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	4	1	02	01	H2320_029_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	029	5	1	02	01	H2320_029_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	029	5	1	02	01	H2320_029_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H2320	029	5	1	02	01	H2320_029_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	5	1	02	01	H2320_029_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.71	50	50	50				50.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	029	5	1	02	01	H2320_029_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	030	1	1	02	01	H2320_030_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	030	1	1	02	01	H2320_030_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H2320	030	1	1	02	01	H2320_030_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	030	1	1	02	01	H2320_030_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.43	50	50	50				29.12	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	030	1	1	02	01	H2320_030_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2320	030	2	1	02	01	H2320_030_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2320	030	2	1	02	01	H2320_030_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H2320	030	2	1	02	01	H2320_030_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	030	2	1	02	01	H2320_030_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.43	50	50	50				29.12	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2320	030	2	1	02	01	H2320_030_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2322	008	0	1	04	01	H2322_008_0	17			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				0.00			0.30	0.00		0.30	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2322	008	0	1	04	01	H2322_008_0	17			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					11.00	22.00	33.00											17.00	34.00	51.00				11.00	22.00	0.00				17.00				11.00			0.57	0.37		0.57	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2322	008	0	1	04	01	H2322_008_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	102.50				47.00				41.00			1.57	1.37		1.57	1.37	1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2322	008	0	1	04	01	H2322_008_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											92.11	50	50	50				82.04	48	48	48										50	50	50				48	48	48			50			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2322	008	0	1	04	01	H2322_008_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			25.00			35.00			25.00			35.00		25.00
H2322	008	0	1	04	01	H2322_008_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2322	008	0	1	04	01	H2322_008_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2322	011	0	1	04	01	H2322_011_0	19			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				0.00			0.30	0.00		0.30	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2322	011	0	1	04	01	H2322_011_0	19			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	51.00					11.00	22.00	33.00											17.00	34.00	51.00				11.00	22.00	0.00				17.00				11.00			0.57	0.37		0.57	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2322	011	0	1	04	01	H2322_011_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	102.50				47.00				41.00			1.57	1.37		1.57	1.37	1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2322	011	0	1	04	01	H2322_011_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											71.34	50	50	50				68.66	48	48	48										50	50	50				48	48	48			50			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2322	011	0	1	04	01	H2322_011_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			25.00			35.00			25.00			35.00		25.00
H2322	011	0	1	04	01	H2322_011_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2322	011	0	1	04	01	H2322_011_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2334	005	0	1	04	01	H2334_005_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2334	005	0	1	04	01	H2334_005_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	42.50					0.00	0.00	0.00											17.00	34.00	42.50				0.00	0.00	0.00				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2334	005	0	1	04	01	H2334_005_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H2334	005	0	1	04	01	H2334_005_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H2334	005	0	1	04	01	H2334_005_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											862.06	29						862.06	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2354	015	0	1	01	01	H2354_015_0	16			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	015	0	1	01	01	H2354_015_0	16			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					9.00	18.00	27.00											16.00	32.00	48.00				9.00	18.00	0.00				16.00				9.00			0.53	0.30		0.53	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	015	0	1	01	01	H2354_015_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	102.50				47.00				41.00			1.57	1.37		1.57	1.37	1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	015	0	1	01	01	H2354_015_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.12	50	50	50				76.66	48	48	48										50	50	50				48	48	48			50			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	015	0	1	01	01	H2354_015_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33						68.66	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			25.00			35.00			25.00			35.00		25.00
H2354	015	0	1	01	01	H2354_015_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	015	0	1	01	01	H2354_015_0	16			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2354	018	0	1	01	01	H2354_018_0	17			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	018	0	1	01	01	H2354_018_0	17			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					9.00	18.00	27.00											16.00	32.00	48.00				9.00	18.00	0.00				16.00				9.00			0.53	0.30		0.53	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	018	0	1	01	01	H2354_018_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	102.50				47.00				41.00			1.57	1.37		1.57	1.37	1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	018	0	1	01	01	H2354_018_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											79.52	50	50	50				72.53	48	48	48										50	50	50				48	48	48			50			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	018	0	1	01	01	H2354_018_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			25.00			35.00			25.00			35.00		25.00
H2354	018	0	1	01	01	H2354_018_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	018	0	1	01	01	H2354_018_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2354	021	0	1	02	01	H2354_021_0	17			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	021	0	1	02	01	H2354_021_0	17			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					9.00	18.00	27.00											16.00	32.00	48.00				9.00	18.00	0.00				16.00				9.00			0.53	0.30		0.53	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	021	0	1	02	01	H2354_021_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	102.50				47.00				41.00			1.57	1.37		1.57	1.37	1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	021	0	1	02	01	H2354_021_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											73.88	50	50	50				68.69	48	48	48										50	50	50				48	48	48			50			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	021	0	1	02	01	H2354_021_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			25.00			35.00			25.00			35.00		35.00
H2354	021	0	1	02	01	H2354_021_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	021	0	1	02	01	H2354_021_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2354	028	0	1	01	01	H2354_028_0	18			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				0.00			0.23	0.00		0.23	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	028	0	1	01	01	H2354_028_0	18			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								16.00	32.00	48.00					9.00	18.00	27.00											16.00	32.00	48.00				9.00	18.00	0.00				16.00				9.00			0.53	0.30		0.53	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	028	0	1	01	01	H2354_028_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	102.50				47.00				41.00			1.57	1.37		1.57	1.37	1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	028	0	1	01	01	H2354_028_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											73.43	50	50	50				77.10	48	48	48										50	50	50				48	48	48			50			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	25.00	50.00	60.00	35.00	70.00	105.00	25.00	50.00	60.00	35.00		25.00
H2354	028	0	1	01	01	H2354_028_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			25.00			35.00			25.00			35.00		25.00
H2354	028	0	1	01	01	H2354_028_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2354	028	0	1	01	01	H2354_028_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2406	008	0	1	04	01	H2406_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	008	0	1	04	01	H2406_008_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	008	0	1	04	01	H2406_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	008	0	1	04	01	H2406_008_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	008	0	1	04	01	H2406_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	008	0	1	04	01	H2406_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	008	0	1	04	01	H2406_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				442.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	009	0	1	04	01	H2406_009_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	009	0	1	04	01	H2406_009_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	009	0	1	04	01	H2406_009_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	009	0	1	04	01	H2406_009_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	009	0	1	04	01	H2406_009_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	009	0	1	04	01	H2406_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	009	0	1	04	01	H2406_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				461.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	010	0	1	04	01	H2406_010_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	010	0	1	04	01	H2406_010_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	010	0	1	04	01	H2406_010_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	010	0	1	04	01	H2406_010_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	010	0	1	04	01	H2406_010_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	010	0	1	04	01	H2406_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	010	0	1	04	01	H2406_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				610.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	011	0	1	04	01	H2406_011_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	011	0	1	04	01	H2406_011_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	011	0	1	04	01	H2406_011_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	011	0	1	04	01	H2406_011_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	011	0	1	04	01	H2406_011_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	011	0	1	04	01	H2406_011_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	011	0	1	04	01	H2406_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				565.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	012	0	1	04	01	H2406_012_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	012	0	1	04	01	H2406_012_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	012	0	1	04	01	H2406_012_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	012	0	1	04	01	H2406_012_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	012	0	1	04	01	H2406_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	012	0	1	04	01	H2406_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	012	0	1	04	01	H2406_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				663.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	013	0	1	04	01	H2406_013_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	013	0	1	04	01	H2406_013_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	013	0	1	04	01	H2406_013_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	013	0	1	04	01	H2406_013_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	013	0	1	04	01	H2406_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	013	0	1	04	01	H2406_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	013	0	1	04	01	H2406_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				511.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	014	0	1	04	01	H2406_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	014	0	1	04	01	H2406_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	014	0	1	04	01	H2406_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	014	0	1	04	01	H2406_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	014	0	1	04	01	H2406_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	014	0	1	04	01	H2406_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	014	0	1	04	01	H2406_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				504.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	015	0	1	04	01	H2406_015_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	015	0	1	04	01	H2406_015_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	015	0	1	04	01	H2406_015_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	015	0	1	04	01	H2406_015_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	015	0	1	04	01	H2406_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	015	0	1	04	01	H2406_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	015	0	1	04	01	H2406_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				487.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	016	0	1	04	01	H2406_016_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	016	0	1	04	01	H2406_016_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	016	0	1	04	01	H2406_016_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	016	0	1	04	01	H2406_016_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	016	0	1	04	01	H2406_016_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	016	0	1	04	01	H2406_016_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	016	0	1	04	01	H2406_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	017	0	1	04	01	H2406_017_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	017	0	1	04	01	H2406_017_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	017	0	1	04	01	H2406_017_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	017	0	1	04	01	H2406_017_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	017	0	1	04	01	H2406_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	017	0	1	04	01	H2406_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	017	0	1	04	01	H2406_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				534.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	018	0	1	04	01	H2406_018_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	018	0	1	04	01	H2406_018_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	018	0	1	04	01	H2406_018_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	018	0	1	04	01	H2406_018_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	018	0	1	04	01	H2406_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	018	0	1	04	01	H2406_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	018	0	1	04	01	H2406_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				557.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	019	0	1	04	01	H2406_019_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	019	0	1	04	01	H2406_019_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	019	0	1	04	01	H2406_019_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	019	0	1	04	01	H2406_019_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	019	0	1	04	01	H2406_019_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	019	0	1	04	01	H2406_019_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	019	0	1	04	01	H2406_019_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				614.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	032	0	1	04	01	H2406_032_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	032	0	1	04	01	H2406_032_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	032	0	1	04	01	H2406_032_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	032	0	1	04	01	H2406_032_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	032	0	1	04	01	H2406_032_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	032	0	1	04	01	H2406_032_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				210.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	034	0	1	04	01	H2406_034_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	034	0	1	04	01	H2406_034_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	034	0	1	04	01	H2406_034_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	034	0	1	04	01	H2406_034_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	034	0	1	04	01	H2406_034_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	034	0	1	04	01	H2406_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	034	0	1	04	01	H2406_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				466.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	035	0	1	04	01	H2406_035_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	035	0	1	04	01	H2406_035_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	035	0	1	04	01	H2406_035_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	035	0	1	04	01	H2406_035_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	035	0	1	04	01	H2406_035_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	035	0	1	04	01	H2406_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	035	0	1	04	01	H2406_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				441.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	036	0	1	04	01	H2406_036_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	036	0	1	04	01	H2406_036_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	036	0	1	04	01	H2406_036_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	036	0	1	04	01	H2406_036_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	036	0	1	04	01	H2406_036_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	036	0	1	04	01	H2406_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	036	0	1	04	01	H2406_036_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				562.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	037	0	1	04	01	H2406_037_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	037	0	1	04	01	H2406_037_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	037	0	1	04	01	H2406_037_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	037	0	1	04	01	H2406_037_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	037	0	1	04	01	H2406_037_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	037	0	1	04	01	H2406_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	037	0	1	04	01	H2406_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				526.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	038	0	1	04	01	H2406_038_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	038	0	1	04	01	H2406_038_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	038	0	1	04	01	H2406_038_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	038	0	1	04	01	H2406_038_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	038	0	1	04	01	H2406_038_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	038	0	1	04	01	H2406_038_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	038	0	1	04	01	H2406_038_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				471.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	039	0	1	04	01	H2406_039_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	039	0	1	04	01	H2406_039_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	039	0	1	04	01	H2406_039_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	039	0	1	04	01	H2406_039_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	039	0	1	04	01	H2406_039_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	039	0	1	04	01	H2406_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	039	0	1	04	01	H2406_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				541.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	040	0	1	04	01	H2406_040_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	040	0	1	04	01	H2406_040_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	040	0	1	04	01	H2406_040_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	040	0	1	04	01	H2406_040_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	040	0	1	04	01	H2406_040_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	040	0	1	04	01	H2406_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	040	0	1	04	01	H2406_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				462.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	042	0	1	04	01	H2406_042_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	042	0	1	04	01	H2406_042_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	042	0	1	04	01	H2406_042_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	042	0	1	04	01	H2406_042_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	042	0	1	04	01	H2406_042_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	042	0	1	04	01	H2406_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	042	0	1	04	01	H2406_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				488.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	043	0	1	04	01	H2406_043_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	043	0	1	04	01	H2406_043_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	043	0	1	04	01	H2406_043_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		12.50																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	043	0	1	04	01	H2406_043_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		12.50																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	043	0	1	04	01	H2406_043_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	043	0	1	04	01	H2406_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	043	0	1	04	01	H2406_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				483.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	044	0	1	04	01	H2406_044_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	044	0	1	04	01	H2406_044_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	044	0	1	04	01	H2406_044_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	044	0	1	04	01	H2406_044_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	044	0	1	04	01	H2406_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	044	0	1	04	01	H2406_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	044	0	1	04	01	H2406_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				471.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	045	0	1	04	01	H2406_045_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	045	0	1	04	01	H2406_045_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	045	0	1	04	01	H2406_045_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	045	0	1	04	01	H2406_045_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	045	0	1	04	01	H2406_045_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	045	0	1	04	01	H2406_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	045	0	1	04	01	H2406_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				444.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	046	0	1	04	01	H2406_046_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	046	0	1	04	01	H2406_046_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	046	0	1	04	01	H2406_046_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	046	0	1	04	01	H2406_046_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	046	0	1	04	01	H2406_046_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	046	0	1	04	01	H2406_046_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	046	0	1	04	01	H2406_046_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				521.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	047	0	1	04	01	H2406_047_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	047	0	1	04	01	H2406_047_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	047	0	1	04	01	H2406_047_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	047	0	1	04	01	H2406_047_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	047	0	1	04	01	H2406_047_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	047	0	1	04	01	H2406_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	047	0	1	04	01	H2406_047_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				415.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	048	0	1	04	01	H2406_048_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	048	0	1	04	01	H2406_048_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	048	0	1	04	01	H2406_048_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	048	0	1	04	01	H2406_048_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	048	0	1	04	01	H2406_048_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	048	0	1	04	01	H2406_048_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	048	0	1	04	01	H2406_048_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				532.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	049	0	1	04	01	H2406_049_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	049	0	1	04	01	H2406_049_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	049	0	1	04	01	H2406_049_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	049	0	1	04	01	H2406_049_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	049	0	1	04	01	H2406_049_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	049	0	1	04	01	H2406_049_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				234.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	054	0	1	04	01	H2406_054_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	054	0	1	04	01	H2406_054_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	054	0	1	04	01	H2406_054_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	054	0	1	04	01	H2406_054_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	054	0	1	04	01	H2406_054_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	054	0	1	04	01	H2406_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	054	0	1	04	01	H2406_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				564.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	055	0	1	04	01	H2406_055_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	055	0	1	04	01	H2406_055_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	055	0	1	04	01	H2406_055_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	055	0	1	04	01	H2406_055_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	055	0	1	04	01	H2406_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	055	0	1	04	01	H2406_055_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	055	0	1	04	01	H2406_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				678.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	056	0	1	04	01	H2406_056_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	056	0	1	04	01	H2406_056_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	056	0	1	04	01	H2406_056_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	056	0	1	04	01	H2406_056_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	056	0	1	04	01	H2406_056_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	056	0	1	04	01	H2406_056_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	056	0	1	04	01	H2406_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				505.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	057	0	1	04	01	H2406_057_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	057	0	1	04	01	H2406_057_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	057	0	1	04	01	H2406_057_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	057	0	1	04	01	H2406_057_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	057	0	1	04	01	H2406_057_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	057	0	1	04	01	H2406_057_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	057	0	1	04	01	H2406_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				490.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	058	0	1	04	01	H2406_058_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	058	0	1	04	01	H2406_058_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	058	0	1	04	01	H2406_058_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	058	0	1	04	01	H2406_058_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	058	0	1	04	01	H2406_058_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	058	0	1	04	01	H2406_058_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	058	0	1	04	01	H2406_058_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				557.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	059	0	1	04	01	H2406_059_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	059	0	1	04	01	H2406_059_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	059	0	1	04	01	H2406_059_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	059	0	1	04	01	H2406_059_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	059	0	1	04	01	H2406_059_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	059	0	1	04	01	H2406_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	059	0	1	04	01	H2406_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				667.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	060	0	1	04	01	H2406_060_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	3.00		6.00																											9.00						0.00				3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	060	0	1	04	01	H2406_060_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	3.00		6.00																											9.00						0.00				3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	060	0	1	04	01	H2406_060_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	060	0	1	04	01	H2406_060_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	060	0	1	04	01	H2406_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	060	0	1	04	01	H2406_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	060	0	1	04	01	H2406_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				595.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	061	0	1	04	01	H2406_061_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	061	0	1	04	01	H2406_061_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	061	0	1	04	01	H2406_061_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	061	0	1	04	01	H2406_061_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	061	0	1	04	01	H2406_061_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	061	0	1	04	01	H2406_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	061	0	1	04	01	H2406_061_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				506.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	062	0	1	04	01	H2406_062_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	062	0	1	04	01	H2406_062_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	062	0	1	04	01	H2406_062_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	062	0	1	04	01	H2406_062_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	062	0	1	04	01	H2406_062_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	062	0	1	04	01	H2406_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	062	0	1	04	01	H2406_062_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				497.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	063	0	1	04	01	H2406_063_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	063	0	1	04	01	H2406_063_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	063	0	1	04	01	H2406_063_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	063	0	1	04	01	H2406_063_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	063	0	1	04	01	H2406_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	063	0	1	04	01	H2406_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	063	0	1	04	01	H2406_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				550.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	064	0	1	04	01	H2406_064_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	064	0	1	04	01	H2406_064_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	064	0	1	04	01	H2406_064_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	064	0	1	04	01	H2406_064_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	064	0	1	04	01	H2406_064_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	064	0	1	04	01	H2406_064_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	064	0	1	04	01	H2406_064_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				683.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	065	0	1	04	01	H2406_065_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	065	0	1	04	01	H2406_065_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	065	0	1	04	01	H2406_065_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	065	0	1	04	01	H2406_065_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	065	0	1	04	01	H2406_065_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	065	0	1	04	01	H2406_065_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	065	0	1	04	01	H2406_065_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				605.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	066	0	1	04	01	H2406_066_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	066	0	1	04	01	H2406_066_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	066	0	1	04	01	H2406_066_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	066	0	1	04	01	H2406_066_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	066	0	1	04	01	H2406_066_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	066	0	1	04	01	H2406_066_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	066	0	1	04	01	H2406_066_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				567.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	067	0	1	04	01	H2406_067_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	067	0	1	04	01	H2406_067_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	067	0	1	04	01	H2406_067_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	067	0	1	04	01	H2406_067_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	067	0	1	04	01	H2406_067_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	067	0	1	04	01	H2406_067_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	067	0	1	04	01	H2406_067_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				555.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	068	0	1	04	01	H2406_068_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	068	0	1	04	01	H2406_068_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	068	0	1	04	01	H2406_068_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	068	0	1	04	01	H2406_068_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	068	0	1	04	01	H2406_068_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	068	0	1	04	01	H2406_068_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	068	0	1	04	01	H2406_068_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				511.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	069	0	1	04	01	H2406_069_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	069	0	1	04	01	H2406_069_0	5			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	069	0	1	04	01	H2406_069_0	5			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	069	0	1	04	01	H2406_069_0	5			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	069	0	1	04	01	H2406_069_0	5			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H2406	069	0	1	04	01	H2406_069_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H2406	069	0	1	04	01	H2406_069_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											451.00	33						516.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	070	0	1	04	01	H2406_070_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	070	0	1	04	01	H2406_070_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	070	0	1	04	01	H2406_070_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	070	0	1	04	01	H2406_070_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	070	0	1	04	01	H2406_070_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	070	0	1	04	01	H2406_070_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	070	0	1	04	01	H2406_070_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				538.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	071	0	1	04	01	H2406_071_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	071	0	1	04	01	H2406_071_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	071	0	1	04	01	H2406_071_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	071	0	1	04	01	H2406_071_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	071	0	1	04	01	H2406_071_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	071	0	1	04	01	H2406_071_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	071	0	1	04	01	H2406_071_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				544.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	072	0	1	04	01	H2406_072_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	072	0	1	04	01	H2406_072_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	072	0	1	04	01	H2406_072_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	072	0	1	04	01	H2406_072_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	072	0	1	04	01	H2406_072_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	072	0	1	04	01	H2406_072_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	072	0	1	04	01	H2406_072_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				333.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	075	0	1	04	01	H2406_075_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	075	0	1	04	01	H2406_075_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	075	0	1	04	01	H2406_075_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	075	0	1	04	01	H2406_075_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	075	0	1	04	01	H2406_075_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	075	0	1	04	01	H2406_075_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	075	0	1	04	01	H2406_075_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				551.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	076	0	1	04	01	H2406_076_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	076	0	1	04	01	H2406_076_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	076	0	1	04	01	H2406_076_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	076	0	1	04	01	H2406_076_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	076	0	1	04	01	H2406_076_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	076	0	1	04	01	H2406_076_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	076	0	1	04	01	H2406_076_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				492.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	078	0	1	04	01	H2406_078_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	078	0	1	04	01	H2406_078_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	078	0	1	04	01	H2406_078_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	078	0	1	04	01	H2406_078_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	078	0	1	04	01	H2406_078_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	078	0	1	04	01	H2406_078_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	078	0	1	04	01	H2406_078_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	079	0	1	04	01	H2406_079_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	079	0	1	04	01	H2406_079_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	079	0	1	04	01	H2406_079_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	079	0	1	04	01	H2406_079_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	079	0	1	04	01	H2406_079_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	079	0	1	04	01	H2406_079_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	079	0	1	04	01	H2406_079_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				760.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	081	0	1	04	01	H2406_081_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	081	0	1	04	01	H2406_081_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	081	0	1	04	01	H2406_081_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	081	0	1	04	01	H2406_081_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	081	0	1	04	01	H2406_081_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	081	0	1	04	01	H2406_081_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	081	0	1	04	01	H2406_081_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				813.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	082	0	1	04	01	H2406_082_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	082	0	1	04	01	H2406_082_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	082	0	1	04	01	H2406_082_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	082	0	1	04	01	H2406_082_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	082	0	1	04	01	H2406_082_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	082	0	1	04	01	H2406_082_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	082	0	1	04	01	H2406_082_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				723.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	083	0	1	04	01	H2406_083_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	083	0	1	04	01	H2406_083_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	083	0	1	04	01	H2406_083_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	20.00		40.00																											60.00						0.00				20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	083	0	1	04	01	H2406_083_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	20.00		40.00																											60.00						0.00				20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	083	0	1	04	01	H2406_083_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	083	0	1	04	01	H2406_083_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	083	0	1	04	01	H2406_083_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				328.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	084	0	1	04	01	H2406_084_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	084	0	1	04	01	H2406_084_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	084	0	1	04	01	H2406_084_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	20.00		40.00																											60.00						0.00				20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	084	0	1	04	01	H2406_084_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	20.00		40.00																											60.00						0.00				20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	084	0	1	04	01	H2406_084_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	084	0	1	04	01	H2406_084_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	084	0	1	04	01	H2406_084_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				349.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	086	0	1	04	01	H2406_086_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	086	0	1	04	01	H2406_086_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	086	0	1	04	01	H2406_086_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	086	0	1	04	01	H2406_086_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	086	0	1	04	01	H2406_086_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	086	0	1	04	01	H2406_086_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	086	0	1	04	01	H2406_086_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				497.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	087	0	1	04	01	H2406_087_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	087	0	1	04	01	H2406_087_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	087	0	1	04	01	H2406_087_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	087	0	1	04	01	H2406_087_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	087	0	1	04	01	H2406_087_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	087	0	1	04	01	H2406_087_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	087	0	1	04	01	H2406_087_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				528.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	088	0	1	04	01	H2406_088_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	088	0	1	04	01	H2406_088_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	088	0	1	04	01	H2406_088_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	088	0	1	04	01	H2406_088_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	088	0	1	04	01	H2406_088_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	088	0	1	04	01	H2406_088_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	088	0	1	04	01	H2406_088_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				676.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	089	0	1	04	01	H2406_089_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	089	0	1	04	01	H2406_089_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	089	0	1	04	01	H2406_089_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	089	0	1	04	01	H2406_089_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	089	0	1	04	01	H2406_089_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	089	0	1	04	01	H2406_089_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	089	0	1	04	01	H2406_089_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				583.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	090	0	1	04	01	H2406_090_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	090	0	1	04	01	H2406_090_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	090	0	1	04	01	H2406_090_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	090	0	1	04	01	H2406_090_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	090	0	1	04	01	H2406_090_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	090	0	1	04	01	H2406_090_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	090	0	1	04	01	H2406_090_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				508.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	091	0	1	04	01	H2406_091_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	091	0	1	04	01	H2406_091_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	091	0	1	04	01	H2406_091_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	091	0	1	04	01	H2406_091_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	091	0	1	04	01	H2406_091_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	091	0	1	04	01	H2406_091_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	091	0	1	04	01	H2406_091_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	093	0	1	04	01	H2406_093_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	093	0	1	04	01	H2406_093_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	093	0	1	04	01	H2406_093_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	093	0	1	04	01	H2406_093_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	093	0	1	04	01	H2406_093_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	093	0	1	04	01	H2406_093_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	093	0	1	04	01	H2406_093_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				455.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	095	0	1	04	01	H2406_095_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	095	0	1	04	01	H2406_095_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	095	0	1	04	01	H2406_095_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	095	0	1	04	01	H2406_095_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	095	0	1	04	01	H2406_095_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	095	0	1	04	01	H2406_095_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	095	0	1	04	01	H2406_095_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				338.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	096	0	1	04	01	H2406_096_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	096	0	1	04	01	H2406_096_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	096	0	1	04	01	H2406_096_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	096	0	1	04	01	H2406_096_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	096	0	1	04	01	H2406_096_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	096	0	1	04	01	H2406_096_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	096	0	1	04	01	H2406_096_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				540.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	097	0	1	04	01	H2406_097_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	097	0	1	04	01	H2406_097_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	097	0	1	04	01	H2406_097_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	097	0	1	04	01	H2406_097_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	097	0	1	04	01	H2406_097_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	097	0	1	04	01	H2406_097_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	097	0	1	04	01	H2406_097_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				636.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	098	0	1	04	01	H2406_098_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	098	0	1	04	01	H2406_098_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	098	0	1	04	01	H2406_098_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	098	0	1	04	01	H2406_098_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	098	0	1	04	01	H2406_098_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	098	0	1	04	01	H2406_098_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	098	0	1	04	01	H2406_098_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				568.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	100	0	1	04	01	H2406_100_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	100	0	1	04	01	H2406_100_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	100	0	1	04	01	H2406_100_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	100	0	1	04	01	H2406_100_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	100	0	1	04	01	H2406_100_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	100	0	1	04	01	H2406_100_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	100	0	1	04	01	H2406_100_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	101	0	1	04	01	H2406_101_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	101	0	1	04	01	H2406_101_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	101	0	1	04	01	H2406_101_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	101	0	1	04	01	H2406_101_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	101	0	1	04	01	H2406_101_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	101	0	1	04	01	H2406_101_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	101	0	1	04	01	H2406_101_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				232.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	102	0	1	04	01	H2406_102_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	102	0	1	04	01	H2406_102_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	102	0	1	04	01	H2406_102_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	102	0	1	04	01	H2406_102_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	102	0	1	04	01	H2406_102_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	102	0	1	04	01	H2406_102_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	102	0	1	04	01	H2406_102_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				513.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	103	0	1	04	01	H2406_103_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	103	0	1	04	01	H2406_103_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	103	0	1	04	01	H2406_103_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	103	0	1	04	01	H2406_103_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	103	0	1	04	01	H2406_103_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	103	0	1	04	01	H2406_103_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	103	0	1	04	01	H2406_103_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				551.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	104	0	1	04	01	H2406_104_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	104	0	1	04	01	H2406_104_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	104	0	1	04	01	H2406_104_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	104	0	1	04	01	H2406_104_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	104	0	1	04	01	H2406_104_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	104	0	1	04	01	H2406_104_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	104	0	1	04	01	H2406_104_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				551.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	105	0	1	04	01	H2406_105_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	105	0	1	04	01	H2406_105_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	105	0	1	04	01	H2406_105_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	105	0	1	04	01	H2406_105_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	105	0	1	04	01	H2406_105_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	105	0	1	04	01	H2406_105_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	105	0	1	04	01	H2406_105_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				551.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	106	0	1	04	01	H2406_106_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	106	0	1	04	01	H2406_106_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	106	0	1	04	01	H2406_106_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	106	0	1	04	01	H2406_106_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	106	0	1	04	01	H2406_106_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	106	0	1	04	01	H2406_106_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	106	0	1	04	01	H2406_106_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				589.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	110	0	1	04	01	H2406_110_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	110	0	1	04	01	H2406_110_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	110	0	1	04	01	H2406_110_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	110	0	1	04	01	H2406_110_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	110	0	1	04	01	H2406_110_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	110	0	1	04	01	H2406_110_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	110	0	1	04	01	H2406_110_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				534.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	111	0	1	04	01	H2406_111_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	111	0	1	04	01	H2406_111_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	111	0	1	04	01	H2406_111_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	111	0	1	04	01	H2406_111_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	111	0	1	04	01	H2406_111_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	111	0	1	04	01	H2406_111_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	111	0	1	04	01	H2406_111_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				534.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	112	0	1	04	01	H2406_112_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	112	0	1	04	01	H2406_112_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	112	0	1	04	01	H2406_112_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	112	0	1	04	01	H2406_112_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	112	0	1	04	01	H2406_112_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	112	0	1	04	01	H2406_112_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	112	0	1	04	01	H2406_112_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				605.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	113	0	1	04	01	H2406_113_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	113	0	1	04	01	H2406_113_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	113	0	1	04	01	H2406_113_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	113	0	1	04	01	H2406_113_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	113	0	1	04	01	H2406_113_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	113	0	1	04	01	H2406_113_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	113	0	1	04	01	H2406_113_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				605.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	114	0	1	04	01	H2406_114_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	114	0	1	04	01	H2406_114_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	114	0	1	04	01	H2406_114_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	114	0	1	04	01	H2406_114_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	114	0	1	04	01	H2406_114_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	114	0	1	04	01	H2406_114_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	114	0	1	04	01	H2406_114_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				447.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	115	0	1	04	01	H2406_115_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	115	0	1	04	01	H2406_115_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	115	0	1	04	01	H2406_115_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	115	0	1	04	01	H2406_115_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	115	0	1	04	01	H2406_115_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	115	0	1	04	01	H2406_115_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	115	0	1	04	01	H2406_115_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				503.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	117	0	1	04	01	H2406_117_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	117	0	1	04	01	H2406_117_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	117	0	1	04	01	H2406_117_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	117	0	1	04	01	H2406_117_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	117	0	1	04	01	H2406_117_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	117	0	1	04	01	H2406_117_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	117	0	1	04	01	H2406_117_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				489.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	119	0	1	04	01	H2406_119_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	119	0	1	04	01	H2406_119_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	119	0	1	04	01	H2406_119_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	119	0	1	04	01	H2406_119_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	119	0	1	04	01	H2406_119_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	119	0	1	04	01	H2406_119_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	119	0	1	04	01	H2406_119_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				272.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	121	0	1	04	01	H2406_121_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	121	0	1	04	01	H2406_121_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	121	0	1	04	01	H2406_121_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	121	0	1	04	01	H2406_121_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2406	121	0	1	04	01	H2406_121_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	121	0	1	04	01	H2406_121_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	121	0	1	04	01	H2406_121_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				531.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	122	0	1	04	01	H2406_122_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	122	0	1	04	01	H2406_122_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	122	0	1	04	01	H2406_122_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	122	0	1	04	01	H2406_122_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	122	0	1	04	01	H2406_122_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	122	0	1	04	01	H2406_122_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	122	0	1	04	01	H2406_122_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				595.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	123	0	1	04	01	H2406_123_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	123	0	1	04	01	H2406_123_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	123	0	1	04	01	H2406_123_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	123	0	1	04	01	H2406_123_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	123	0	1	04	01	H2406_123_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	123	0	1	04	01	H2406_123_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	123	0	1	04	01	H2406_123_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				565.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	124	0	1	04	01	H2406_124_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	124	0	1	04	01	H2406_124_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	124	0	1	04	01	H2406_124_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	124	0	1	04	01	H2406_124_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	124	0	1	04	01	H2406_124_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	124	0	1	04	01	H2406_124_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	124	0	1	04	01	H2406_124_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	125	0	1	04	01	H2406_125_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	125	0	1	04	01	H2406_125_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	125	0	1	04	01	H2406_125_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	125	0	1	04	01	H2406_125_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	125	0	1	04	01	H2406_125_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	125	0	1	04	01	H2406_125_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	125	0	1	04	01	H2406_125_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				404.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	126	0	1	04	01	H2406_126_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	126	0	1	04	01	H2406_126_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2406	126	0	1	04	01	H2406_126_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2406	126	0	1	04	01	H2406_126_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2406	126	0	1	04	01	H2406_126_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	126	0	1	04	01	H2406_126_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2406	126	0	1	04	01	H2406_126_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	001	0	1	18	06	H2450_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	4.00				10.00				2.00			0.33	0.07		0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	001	0	1	18	06	H2450_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	16.00				20.00				8.00			0.67	0.27		0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	16.00	20.00		8.00
H2450	001	0	1	18	06	H2450_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	70.00				47.00				35.00			1.57	1.17		1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	001	0	1	18	06	H2450_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.83	50	50	50				47.21	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	001	0	1	18	06	H2450_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	002	0	1	18	06	H2450_002_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	4.00				10.00				2.00			0.33	0.07		0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	002	0	1	18	06	H2450_002_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	16.00				20.00				8.00			0.67	0.27		0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	16.00	20.00		8.00
H2450	002	0	1	18	06	H2450_002_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	70.00				47.00				35.00			1.57	1.17		1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	002	0	1	18	06	H2450_002_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.61	50	50	50				51.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	002	0	1	18	06	H2450_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	007	0	1	18	06	H2450_007_0	5			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	20.00				15.00				10.00			0.50	0.33		0.50	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	007	0	1	18	06	H2450_007_0	5			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	30.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	30.00	20.00		15.00
H2450	007	0	1	18	06	H2450_007_0	5			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	007	0	1	18	06	H2450_007_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.91	50	50	50				81.22	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	007	0	1	18	06	H2450_007_0	5			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	016	0	1	18	06	H2450_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	016	0	1	18	06	H2450_016_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	20.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	20.00	20.00		10.00
H2450	016	0	1	18	06	H2450_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	70.00				47.00				35.00			1.57	1.17		1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	016	0	1	18	06	H2450_016_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.53	50	50	50				85.02	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	016	0	1	18	06	H2450_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	035	0	1	18	06	H2450_035_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	035	0	1	18	06	H2450_035_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H2450	035	0	1	18	06	H2450_035_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2450	035	0	1	18	06	H2450_035_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				79.94	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2450	035	0	1	18	06	H2450_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	037	0	1	18	06	H2450_037_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	037	0	1	18	06	H2450_037_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H2450	037	0	1	18	06	H2450_037_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2450	037	0	1	18	06	H2450_037_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				78.43	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2450	037	0	1	18	06	H2450_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	039	0	1	18	06	H2450_039_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	4.00				10.00				2.00			0.33	0.07		0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	039	0	1	18	06	H2450_039_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	20.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	20.00	20.00		10.00
H2450	039	0	1	18	06	H2450_039_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	80.00				47.00				40.00			1.57	1.33		1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	039	0	1	18	06	H2450_039_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.01	50	50	50				91.38	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	039	0	1	18	06	H2450_039_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	041	0	1	18	06	H2450_041_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	041	0	1	18	06	H2450_041_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	20.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	20.00	20.00		10.00
H2450	041	0	1	18	06	H2450_041_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	80.00				47.00				40.00			1.57	1.33		1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	041	0	1	18	06	H2450_041_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.21	50	50	50				84.79	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H2450	041	0	1	18	06	H2450_041_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	049	0	1	18	06	H2450_049_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2450	049	0	1	18	06	H2450_049_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H2450	049	0	1	18	06	H2450_049_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2450	049	0	1	18	06	H2450_049_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				44.54	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2450	049	0	1	18	06	H2450_049_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	1	1	02	01	H2459_021_1	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	1	1	02	01	H2459_021_1	8			Preferred Generic	4	11	1	2	1	3	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2459	021	1	1	02	01	H2459_021_1	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	7.00	14.00	21.00																			7.00	14.00	14.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	1	1	02	01	H2459_021_1	8			Generic	4	11	1	2	2	3	111		10	111		1	30	60	100				1	2	30	60	100					29	31	7.00	14.00	21.00																			7.00	14.00	14.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2459	021	1	1	02	01	H2459_021_1	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	35.00	70.00	105.00																			35.00	70.00	70.00																	35.00			35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	021	1	1	02	01	H2459_021_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	1	1	02	01	H2459_021_1	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				3338.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	2	1	02	01	H2459_021_2	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	2	1	02	01	H2459_021_2	8			Preferred Generic	4	11	1	2	1	3	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2459	021	2	1	02	01	H2459_021_2	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	7.00	14.00	21.00																			7.00	14.00	14.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	2	1	02	01	H2459_021_2	8			Generic	4	11	1	2	2	3	111		10	111		1	30	60	100				1	2	30	60	100					29	31	7.00	14.00	21.00																			7.00	14.00	14.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2459	021	2	1	02	01	H2459_021_2	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	35.00	70.00	105.00																			35.00	70.00	70.00																	35.00			35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	021	2	1	02	01	H2459_021_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	2	1	02	01	H2459_021_2	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				3338.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	3	1	02	01	H2459_021_3	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	3	1	02	01	H2459_021_3	8			Preferred Generic	4	11	1	2	1	3	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2459	021	3	1	02	01	H2459_021_3	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	7.00	14.00	21.00																			7.00	14.00	14.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	3	1	02	01	H2459_021_3	8			Generic	4	11	1	2	2	3	111		10	111		1	30	60	100				1	2	30	60	100					29	31	7.00	14.00	21.00																			7.00	14.00	14.00																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2459	021	3	1	02	01	H2459_021_3	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	35.00	70.00	105.00																			35.00	70.00	70.00																	35.00			35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	021	3	1	02	01	H2459_021_3	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	021	3	1	02	01	H2459_021_3	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				3338.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	1	1	02	01	H2459_023_1	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	1	1	02	01	H2459_023_1	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	1	1	02	01	H2459_023_1	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	023	1	1	02	01	H2459_023_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	1	1	02	01	H2459_023_1	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2675.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	2	1	02	01	H2459_023_2	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	2	1	02	01	H2459_023_2	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	2	1	02	01	H2459_023_2	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	023	2	1	02	01	H2459_023_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	023	2	1	02	01	H2459_023_2	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2675.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	024	0	1	02	01	H2459_024_0	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	024	0	1	02	01	H2459_024_0	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	024	0	1	02	01	H2459_024_0	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	024	0	1	02	01	H2459_024_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	024	0	1	02	01	H2459_024_0	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1878.00	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	1	1	02	01	H2459_026_1	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	1	1	02	01	H2459_026_1	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	1	1	02	01	H2459_026_1	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	026	1	1	02	01	H2459_026_1	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	1	1	02	01	H2459_026_1	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2008.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	3	1	02	01	H2459_026_3	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	3	1	02	01	H2459_026_3	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	3	1	02	01	H2459_026_3	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	026	3	1	02	01	H2459_026_3	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	3	1	02	01	H2459_026_3	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2008.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	4	1	02	01	H2459_026_4	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	4	1	02	01	H2459_026_4	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	4	1	02	01	H2459_026_4	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	026	4	1	02	01	H2459_026_4	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	026	4	1	02	01	H2459_026_4	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2008.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	029	0	1	02	01	H2459_029_0	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	029	0	1	02	01	H2459_029_0	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	029	0	1	02	01	H2459_029_0	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	029	0	1	02	01	H2459_029_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	029	0	1	02	01	H2459_029_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2161.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	031	0	1	01	01	H2459_031_0	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	3.00	6.00	9.00																			3.00	6.00	6.00																	3.00			3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	031	0	1	01	01	H2459_031_0	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	15.00	30.00	45.00																			15.00	30.00	30.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	031	0	1	01	01	H2459_031_0	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	031	0	1	01	01	H2459_031_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	031	0	1	01	01	H2459_031_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2414.00	31																				31																		31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	032	0	1	01	01	H2459_032_0	9			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	2.00	4.00	6.00																			2.00	4.00	4.00																	2.00			2.00		0.07			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	032	0	1	01	01	H2459_032_0	9			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	12.00	24.00	36.00																			12.00	24.00	24.00																	12.00			12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	032	0	1	01	01	H2459_032_0	9			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2459	032	0	1	01	01	H2459_032_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2459	032	0	1	01	01	H2459_032_0	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2570.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2461	008	0	1	18	06	H2461_008_0	9			Preferred Generic	2	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H2461	008	0	1	18	06	H2461_008_0	9			Generic	2	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	11.00	22.00	22.00																									16.00	32.00	32.00				11.00	22.00	22.00				11.00				11.00		0.35				0.52	0.35	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	22.00				16.00	32.00	32.00	11.00	22.00	22.00	11.00		11.00
H2461	008	0	1	18	06	H2461_008_0	9			Preferred Brand	2	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				58.36	22	22	22																								24	24	24				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2461	008	0	1	18	06	H2461_008_0	9			Non-Preferred Drug	2	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				98.78	44	44	44																								46	46	46				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2461	008	0	1	18	06	H2461_008_0	9			Specialty Tier	2	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					25	25	25																								25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2461	009	0	1	18	06	H2461_009_0	9			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H2461	009	0	1	18	06	H2461_009_0	9			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	15.00	30.00	30.00																									20.00	40.00	40.00				15.00	30.00	30.00				15.00				15.00		0.48				0.64	0.48	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	30.00				20.00	40.00	40.00	15.00	30.00	30.00	15.00		15.00
H2461	009	0	1	18	06	H2461_009_0	9			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				80.90	21	21	21																								23	23	23				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2461	009	0	1	18	06	H2461_009_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				99.63	42	42	42																								44	44	44				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2461	009	0	1	18	06	H2461_009_0	9			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					25	25	25																								25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2461	010	0	1	18	06	H2461_010_0	9			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H2461	010	0	1	18	06	H2461_010_0	9			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	9.00	18.00	18.00																									14.00	28.00	28.00				9.00	18.00	18.00				9.00				9.00		0.29				0.45	0.29	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	18.00				14.00	28.00	28.00	9.00	18.00	18.00	9.00		9.00
H2461	010	0	1	18	06	H2461_010_0	9			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				70.01	20	20	20																								22	22	22				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2461	010	0	1	18	06	H2461_010_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				91.27	40	40	40																								42	42	42				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H2461	010	0	1	18	06	H2461_010_0	9			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					25	25	25																								25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2463	001	0	1	01	01	H2463_001_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H2463	001	0	1	01	01	H2463_001_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H2463	001	0	1	01	01	H2463_001_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H2463	001	0	1	01	01	H2463_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2463	001	0	1	01	01	H2463_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2478	002	0	1	01	01	H2478_002_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2478	002	0	1	01	01	H2478_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2478	002	0	1	01	01	H2478_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H2478	002	0	1	01	01	H2478_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2478	002	0	1	01	01	H2478_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1144.34	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H2478	002	0	1	01	01	H2478_002_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2486	003	0	1	01	01	H2486_003_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H2486	003	0	1	01	01	H2486_003_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	003	0	1	01	01	H2486_003_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H2486	003	0	1	01	01	H2486_003_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	003	0	1	01	01	H2486_003_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	003	0	1	01	01	H2486_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	003	0	1	01	01	H2486_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2486	005	0	1	01	01	H2486_005_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H2486	005	0	1	01	01	H2486_005_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	005	0	1	01	01	H2486_005_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H2486	005	0	1	01	01	H2486_005_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	005	0	1	01	01	H2486_005_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	005	0	1	01	01	H2486_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	005	0	1	01	01	H2486_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2486	006	0	1	01	01	H2486_006_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H2486	006	0	1	01	01	H2486_006_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2486	006	0	1	01	01	H2486_006_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H2486	006	0	1	01	01	H2486_006_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2486	006	0	1	01	01	H2486_006_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	006	0	1	01	01	H2486_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	006	0	1	01	01	H2486_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2486	007	0	1	01	01	H2486_007_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H2486	007	0	1	01	01	H2486_007_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	007	0	1	01	01	H2486_007_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H2486	007	0	1	01	01	H2486_007_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	007	0	1	01	01	H2486_007_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	007	0	1	01	01	H2486_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	007	0	1	01	01	H2486_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2486	009	0	1	01	01	H2486_009_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H2486	009	0	1	01	01	H2486_009_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	009	0	1	01	01	H2486_009_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H2486	009	0	1	01	01	H2486_009_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	009	0	1	01	01	H2486_009_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	009	0	1	01	01	H2486_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	009	0	1	01	01	H2486_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2486	010	0	1	01	01	H2486_010_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H2486	010	0	1	01	01	H2486_010_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	010	0	1	01	01	H2486_010_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	14.00		42.00																									20.00		60.00				14.00		0.00				14.00				14.00		0.47				0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00		42.00				20.00		60.00	14.00		0.00	14.00		14.00
H2486	010	0	1	01	01	H2486_010_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	14.00		42.00																									20.00		60.00				14.00		0.00				14.00				14.00		0.47				0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2486	010	0	1	01	01	H2486_010_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	010	0	1	01	01	H2486_010_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2486	010	0	1	01	01	H2486_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2491	009	0	1	01	01	H2491_009_0	20			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	009	0	1	01	01	H2491_009_0	20			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	009	0	1	01	01	H2491_009_0	20			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	009	0	1	01	01	H2491_009_0	20			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.00	31	31	31				98.00	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	009	0	1	01	01	H2491_009_0	20			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	009	0	1	01	01	H2491_009_0	20			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	010	0	1	01	01	H2491_010_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	010	0	1	01	01	H2491_010_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	010	0	1	01	01	H2491_010_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H2491	010	0	1	01	01	H2491_010_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.87	50	50	50				99.87	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	010	0	1	01	01	H2491_010_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	010	0	1	01	01	H2491_010_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	015	0	1	01	01	H2491_015_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	015	0	1	01	01	H2491_015_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	015	0	1	01	01	H2491_015_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	015	0	1	01	01	H2491_015_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.19	50	50	50				98.19	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	015	0	1	01	01	H2491_015_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	015	0	1	01	01	H2491_015_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	016	0	1	01	01	H2491_016_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	016	0	1	01	01	H2491_016_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2491	016	0	1	01	01	H2491_016_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	016	0	1	01	01	H2491_016_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2491	016	0	1	01	01	H2491_016_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	016	0	1	01	01	H2491_016_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.51	50	50	50				92.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	016	0	1	01	01	H2491_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	016	0	1	01	01	H2491_016_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	016	0	1	01	01	H2491_016_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2491	017	0	1	01	01	H2491_017_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	017	0	1	01	01	H2491_017_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	017	0	1	01	01	H2491_017_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	017	0	1	01	01	H2491_017_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.99	50	50	50				84.99	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	017	0	1	01	01	H2491_017_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	017	0	1	01	01	H2491_017_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	017	0	1	01	01	H2491_017_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2491	021	0	1	01	01	H2491_021_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	021	0	1	01	01	H2491_021_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	021	0	1	01	01	H2491_021_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	021	0	1	01	01	H2491_021_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.95	50	50	50				83.95	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	021	0	1	01	01	H2491_021_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	021	0	1	01	01	H2491_021_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	021	0	1	01	01	H2491_021_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2491	027	1	1	01	01	H2491_027_1	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	1	1	01	01	H2491_027_1	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	1	1	01	01	H2491_027_1	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	027	1	1	01	01	H2491_027_1	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.25	50	50	50				91.25	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	027	1	1	01	01	H2491_027_1	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	027	1	1	01	01	H2491_027_1	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	1	1	01	01	H2491_027_1	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2491	027	2	1	01	01	H2491_027_2	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	2	1	01	01	H2491_027_2	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	2	1	01	01	H2491_027_2	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	027	2	1	01	01	H2491_027_2	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.25	50	50	50				91.25	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	027	2	1	01	01	H2491_027_2	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	027	2	1	01	01	H2491_027_2	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	2	1	01	01	H2491_027_2	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2491	027	3	1	01	01	H2491_027_3	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	3	1	01	01	H2491_027_3	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	3	1	01	01	H2491_027_3	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2491	027	3	1	01	01	H2491_027_3	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.25	50	50	50				91.25	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2491	027	3	1	01	01	H2491_027_3	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2491	027	3	1	01	01	H2491_027_3	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2491	027	3	1	01	01	H2491_027_3	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2506	001	0	1	48	05	H2506_001_0	3			Generic Drugs	4	11		2	1	1	111		10	111		1	30	60	90				2	2	30	60	90					29	31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H2506	001	0	1	48	05	H2506_001_0	3			Brand Drugs	4	11		2	2	1	111		10	111		1	30	60	90				2	2	30	60	90					29	31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H2506	001	0	1	48	05	H2506_001_0	3			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		10	000		1	30	60	90				1	2								29	31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00			0.00	0.00																		
H2526	001	0	1	04	01	H2526_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2526	001	0	1	04	01	H2526_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2526	001	0	1	04	01	H2526_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2526	001	0	1	04	01	H2526_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2526	001	0	1	04	01	H2526_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2526	001	0	1	04	01	H2526_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2526	001	0	1	04	01	H2526_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2531	001	0	1	48	05	H2531_001_0	2			Generic Drugs	4	01			1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																																					Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	4.50	0.00	4.50	0.00	4.50	0.00	4.50																		
H2531	001	0	1	48	05	H2531_001_0	2			Brand Drugs	4	10			2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																																					Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	11.20	0.00	11.20	0.00	11.20	0.00	11.20																		
H2531	001	0	1	48	05	H2531_001_0	2			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H2533	001	0	1	48	05	H2533_001_0	6			Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H2533	001	0	1	48	05	H2533_001_0	6			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H2533	001	0	1	48	05	H2533_001_0	6			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31								31						31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H2563	005	1	1	01	01	H2563_005_1	10			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	1	1	01	01	H2563_005_1	10			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					8.00		20.00							0.00																15.00				8.00			0.50	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	1	1	01	01	H2563_005_1	10			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								45.00		112.50					40.00		100.00							80.00																45.00				40.00			1.50	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	005	1	1	01	01	H2563_005_1	10			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								95.00		285.00					90.00		270.00							270.00																95.00				90.00			3.17	3.00				2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	1	1	01	01	H2563_005_1	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											961.37	30						1010.14	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	2	1	01	01	H2563_005_2	10			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	2	1	01	01	H2563_005_2	10			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					8.00		20.00							0.00																15.00				8.00			0.50	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	2	1	01	01	H2563_005_2	10			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								45.00		112.50					40.00		100.00							80.00																45.00				40.00			1.50	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	005	2	1	01	01	H2563_005_2	10			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								95.00		285.00					90.00		270.00							270.00																95.00				90.00			3.17	3.00				2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	005	2	1	01	01	H2563_005_2	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											961.37	30						1010.14	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	008	0	1	01	01	H2563_008_0	10			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	008	0	1	01	01	H2563_008_0	10			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	008	0	1	01	01	H2563_008_0	10			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	008	0	1	01	01	H2563_008_0	10			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	008	0	1	01	01	H2563_008_0	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											649.70	30						860.01	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	009	0	1	01	01	H2563_009_0	10			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	009	0	1	01	01	H2563_009_0	10			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	009	0	1	01	01	H2563_009_0	10			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	009	0	1	01	01	H2563_009_0	10			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	009	0	1	01	01	H2563_009_0	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1417.58	30						876.56	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	015	0	1	01	01	H2563_015_0	11			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	015	0	1	01	01	H2563_015_0	11			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	015	0	1	01	01	H2563_015_0	11			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	015	0	1	01	01	H2563_015_0	11			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	015	0	1	01	01	H2563_015_0	11			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1002.50	30						804.48	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	016	0	1	01	01	H2563_016_0	10			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	016	0	1	01	01	H2563_016_0	10			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	016	0	1	01	01	H2563_016_0	10			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	016	0	1	01	01	H2563_016_0	10			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	016	0	1	01	01	H2563_016_0	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1014.40	30						681.96	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	1	1	01	01	H2563_017_1	10			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	1	1	01	01	H2563_017_1	10			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	1	1	01	01	H2563_017_1	10			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	017	1	1	01	01	H2563_017_1	10			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	1	1	01	01	H2563_017_1	10			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1035.65	30						823.05	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	2	1	01	01	H2563_017_2	9			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	2	1	01	01	H2563_017_2	9			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	2	1	01	01	H2563_017_2	9			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	017	2	1	01	01	H2563_017_2	9			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	017	2	1	01	01	H2563_017_2	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1035.65	30						823.05	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	018	0	1	01	01	H2563_018_0	9			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	018	0	1	01	01	H2563_018_0	9			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	018	0	1	01	01	H2563_018_0	9			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00	0.00		0.00			0.00				0.00		0.00
H2563	018	0	1	01	01	H2563_018_0	9			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	018	0	1	01	01	H2563_018_0	9			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1162.06	30						1162.06	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	019	0	1	01	01	H2563_019_0	8			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		100	2	2			100				30		31								5.00		12.50					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	019	0	1	01	01	H2563_019_0	8			Generic	4	01	3	2	2	1		110	01	100		1				30		90	2	2			90				30		31								15.00		37.50					10.00		25.00							0.00																15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	019	0	1	01	01	H2563_019_0	8			Preferred Brand	4	11	1	2	3	1		110	01	100		1				30		90	2	2			90				30		31								47.00		117.50					42.00		105.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50	35.00		87.50			70.00				35.00		35.00
H2563	019	0	1	01	01	H2563_019_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01	100		1				30		90	2	2			90				30		31								100.00		300.00					95.00		285.00							285.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2563	019	0	1	01	01	H2563_019_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											1045.21	30						834.51	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	001	1	1	04	01	H2577_001_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	001	1	1	04	01	H2577_001_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	001	1	1	04	01	H2577_001_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	001	1	1	04	01	H2577_001_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	001	1	1	04	01	H2577_001_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	001	1	1	04	01	H2577_001_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	001	1	1	04	01	H2577_001_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				331.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	001	2	1	04	01	H2577_001_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	001	2	1	04	01	H2577_001_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	001	2	1	04	01	H2577_001_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	001	2	1	04	01	H2577_001_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	001	2	1	04	01	H2577_001_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	001	2	1	04	01	H2577_001_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	001	2	1	04	01	H2577_001_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				331.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	002	0	1	04	01	H2577_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	002	0	1	04	01	H2577_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	002	0	1	04	01	H2577_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	002	0	1	04	01	H2577_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	002	0	1	04	01	H2577_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	002	0	1	04	01	H2577_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	002	0	1	04	01	H2577_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				230.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	003	1	1	04	01	H2577_003_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	003	1	1	04	01	H2577_003_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	003	1	1	04	01	H2577_003_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	003	1	1	04	01	H2577_003_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	003	1	1	04	01	H2577_003_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	003	1	1	04	01	H2577_003_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	003	1	1	04	01	H2577_003_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				731.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	003	2	1	04	01	H2577_003_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	003	2	1	04	01	H2577_003_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	003	2	1	04	01	H2577_003_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	003	2	1	04	01	H2577_003_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	003	2	1	04	01	H2577_003_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	003	2	1	04	01	H2577_003_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	003	2	1	04	01	H2577_003_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				731.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	004	0	1	04	01	H2577_004_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	004	0	1	04	01	H2577_004_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	004	0	1	04	01	H2577_004_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	004	0	1	04	01	H2577_004_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	004	0	1	04	01	H2577_004_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	004	0	1	04	01	H2577_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	004	0	1	04	01	H2577_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				572.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	005	0	1	04	01	H2577_005_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	005	0	1	04	01	H2577_005_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	005	0	1	04	01	H2577_005_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	005	0	1	04	01	H2577_005_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	005	0	1	04	01	H2577_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	005	0	1	04	01	H2577_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	005	0	1	04	01	H2577_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				320.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	006	0	1	04	01	H2577_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	006	0	1	04	01	H2577_006_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	006	0	1	04	01	H2577_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	006	0	1	04	01	H2577_006_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	006	0	1	04	01	H2577_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	006	0	1	04	01	H2577_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	006	0	1	04	01	H2577_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				596.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	007	0	1	04	01	H2577_007_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	007	0	1	04	01	H2577_007_0	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	007	0	1	04	01	H2577_007_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	007	0	1	04	01	H2577_007_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	007	0	1	04	01	H2577_007_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	007	0	1	04	01	H2577_007_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	007	0	1	04	01	H2577_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				647.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	008	0	1	04	01	H2577_008_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	008	0	1	04	01	H2577_008_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	008	0	1	04	01	H2577_008_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	008	0	1	04	01	H2577_008_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	008	0	1	04	01	H2577_008_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	008	0	1	04	01	H2577_008_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	008	0	1	04	01	H2577_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				578.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	009	0	1	04	01	H2577_009_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	009	0	1	04	01	H2577_009_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	009	0	1	04	01	H2577_009_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	009	0	1	04	01	H2577_009_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	009	0	1	04	01	H2577_009_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	009	0	1	04	01	H2577_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	009	0	1	04	01	H2577_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				279.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	011	0	1	04	01	H2577_011_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	011	0	1	04	01	H2577_011_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	011	0	1	04	01	H2577_011_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	011	0	1	04	01	H2577_011_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	011	0	1	04	01	H2577_011_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	011	0	1	04	01	H2577_011_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	011	0	1	04	01	H2577_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				698.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	013	0	1	04	01	H2577_013_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	013	0	1	04	01	H2577_013_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	013	0	1	04	01	H2577_013_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	013	0	1	04	01	H2577_013_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	013	0	1	04	01	H2577_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	013	0	1	04	01	H2577_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	013	0	1	04	01	H2577_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				587.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	014	0	1	04	01	H2577_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	014	0	1	04	01	H2577_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	014	0	1	04	01	H2577_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	014	0	1	04	01	H2577_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	014	0	1	04	01	H2577_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	014	0	1	04	01	H2577_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	014	0	1	04	01	H2577_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	016	0	1	04	01	H2577_016_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	016	0	1	04	01	H2577_016_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	016	0	1	04	01	H2577_016_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	016	0	1	04	01	H2577_016_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	016	0	1	04	01	H2577_016_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	016	0	1	04	01	H2577_016_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	016	0	1	04	01	H2577_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				401.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	017	0	1	04	01	H2577_017_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	017	0	1	04	01	H2577_017_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	017	0	1	04	01	H2577_017_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	017	0	1	04	01	H2577_017_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	017	0	1	04	01	H2577_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	017	0	1	04	01	H2577_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	017	0	1	04	01	H2577_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				237.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	018	0	1	04	01	H2577_018_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	018	0	1	04	01	H2577_018_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	018	0	1	04	01	H2577_018_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	018	0	1	04	01	H2577_018_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	018	0	1	04	01	H2577_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	018	0	1	04	01	H2577_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	018	0	1	04	01	H2577_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				459.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	020	0	1	04	01	H2577_020_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	020	0	1	04	01	H2577_020_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	020	0	1	04	01	H2577_020_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	020	0	1	04	01	H2577_020_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	020	0	1	04	01	H2577_020_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	020	0	1	04	01	H2577_020_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	020	0	1	04	01	H2577_020_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				498.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	021	0	1	04	01	H2577_021_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	021	0	1	04	01	H2577_021_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	021	0	1	04	01	H2577_021_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	021	0	1	04	01	H2577_021_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2577	021	0	1	04	01	H2577_021_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	021	0	1	04	01	H2577_021_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	021	0	1	04	01	H2577_021_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				500.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	022	0	1	04	01	H2577_022_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	022	0	1	04	01	H2577_022_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	022	0	1	04	01	H2577_022_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	022	0	1	04	01	H2577_022_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	022	0	1	04	01	H2577_022_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	022	0	1	04	01	H2577_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	022	0	1	04	01	H2577_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				576.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	023	0	1	04	01	H2577_023_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	023	0	1	04	01	H2577_023_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	023	0	1	04	01	H2577_023_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	023	0	1	04	01	H2577_023_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	023	0	1	04	01	H2577_023_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	023	0	1	04	01	H2577_023_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	023	0	1	04	01	H2577_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				588.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	026	0	1	04	01	H2577_026_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	026	0	1	04	01	H2577_026_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	026	0	1	04	01	H2577_026_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	026	0	1	04	01	H2577_026_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	026	0	1	04	01	H2577_026_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	026	0	1	04	01	H2577_026_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	026	0	1	04	01	H2577_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				336.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	027	0	1	04	01	H2577_027_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	027	0	1	04	01	H2577_027_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	027	0	1	04	01	H2577_027_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	027	0	1	04	01	H2577_027_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	027	0	1	04	01	H2577_027_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	027	0	1	04	01	H2577_027_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	027	0	1	04	01	H2577_027_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	028	0	1	04	01	H2577_028_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	028	0	1	04	01	H2577_028_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	028	0	1	04	01	H2577_028_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	028	0	1	04	01	H2577_028_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2577	028	0	1	04	01	H2577_028_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	028	0	1	04	01	H2577_028_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	028	0	1	04	01	H2577_028_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				586.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	030	0	1	04	01	H2577_030_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	030	0	1	04	01	H2577_030_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	030	0	1	04	01	H2577_030_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	030	0	1	04	01	H2577_030_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	030	0	1	04	01	H2577_030_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	030	0	1	04	01	H2577_030_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	030	0	1	04	01	H2577_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				709.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	031	0	1	04	01	H2577_031_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	031	0	1	04	01	H2577_031_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2577	031	0	1	04	01	H2577_031_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2577	031	0	1	04	01	H2577_031_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2577	031	0	1	04	01	H2577_031_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	031	0	1	04	01	H2577_031_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2577	031	0	1	04	01	H2577_031_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				532.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2582	004	0	1	02	01	H2582_004_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2582	004	0	1	02	01	H2582_004_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2582	004	0	1	02	01	H2582_004_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2582	004	0	1	02	01	H2582_004_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2582	004	0	1	02	01	H2582_004_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2582	004	0	1	02	01	H2582_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2582	004	0	1	02	01	H2582_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				561.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2582	005	0	1	02	01	H2582_005_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2582	005	0	1	02	01	H2582_005_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2582	005	0	1	02	01	H2582_005_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2582	005	0	1	02	01	H2582_005_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2582	005	0	1	02	01	H2582_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2582	005	0	1	02	01	H2582_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2582	005	0	1	02	01	H2582_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				683.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2593	001	0	1	01	01	H2593_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	001	0	1	01	01	H2593_001_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	001	0	1	01	01	H2593_001_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	001	0	1	01	01	H2593_001_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	001	0	1	01	01	H2593_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	001	0	1	01	01	H2593_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	001	0	1	01	01	H2593_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	001	0	1	01	01	H2593_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H2593	001	0	1	01	01	H2593_001_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	003	0	1	01	01	H2593_003_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	003	0	1	01	01	H2593_003_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	003	0	1	01	01	H2593_003_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	003	0	1	01	01	H2593_003_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	003	0	1	01	01	H2593_003_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2593	003	0	1	01	01	H2593_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H2593	003	0	1	01	01	H2593_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	003	0	1	01	01	H2593_003_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2593	003	0	1	01	01	H2593_003_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	005	0	1	01	01	H2593_005_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	005	0	1	01	01	H2593_005_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	005	0	1	01	01	H2593_005_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	005	0	1	01	01	H2593_005_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	005	0	1	01	01	H2593_005_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	005	0	1	01	01	H2593_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	005	0	1	01	01	H2593_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	005	0	1	01	01	H2593_005_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H2593	005	0	1	01	01	H2593_005_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	006	0	1	01	01	H2593_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	006	0	1	01	01	H2593_006_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	006	0	1	01	01	H2593_006_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	006	0	1	01	01	H2593_006_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	006	0	1	01	01	H2593_006_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	006	0	1	01	01	H2593_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	006	0	1	01	01	H2593_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	006	0	1	01	01	H2593_006_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H2593	006	0	1	01	01	H2593_006_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	029	0	1	01	01	H2593_029_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	029	0	1	01	01	H2593_029_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	029	0	1	01	01	H2593_029_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	029	0	1	01	01	H2593_029_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	029	0	1	01	01	H2593_029_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	029	0	1	01	01	H2593_029_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	029	0	1	01	01	H2593_029_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	031	0	1	02	01	H2593_031_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								7.00	14.00	21.00					2.00	4.00	6.00					0.00	0.00	0.00																7.00				7.00			0.23	0.07	0.00			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	031	0	1	02	01	H2593_031_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.00	24.00	36.00					7.00	14.00	21.00					0.00	0.00	0.00																12.00				12.00			0.40	0.23	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	031	0	1	02	01	H2593_031_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2593	031	0	1	02	01	H2593_031_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								98.00	196.00	294.00					93.00	186.00	279.00					93.00	279.00	279.00																98.00				98.00			3.27	3.10	3.10			2.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	031	0	1	02	01	H2593_031_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	031	0	1	02	01	H2593_031_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	031	0	1	02	01	H2593_031_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	040	0	1	01	01	H2593_040_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	040	0	1	01	01	H2593_040_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	040	0	1	01	01	H2593_040_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	040	0	1	01	01	H2593_040_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	040	0	1	01	01	H2593_040_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	040	0	1	01	01	H2593_040_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H2593	040	0	1	01	01	H2593_040_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	040	0	1	01	01	H2593_040_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H2593	040	0	1	01	01	H2593_040_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2593	043	0	1	01	01	H2593_043_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	043	0	1	01	01	H2593_043_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								17.00	34.00	51.00					12.00	24.00	36.00					0.00	0.00	0.00																17.00				17.00			0.57	0.40	0.00			0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	043	0	1	01	01	H2593_043_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2593	043	0	1	01	01	H2593_043_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	043	0	1	01	01	H2593_043_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	043	0	1	01	01	H2593_043_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2593	043	0	1	01	01	H2593_043_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2610	005	0	1	01	01	H2610_005_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H2610	005	0	1	01	01	H2610_005_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H2610	005	0	1	01	01	H2610_005_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H2610	005	0	1	01	01	H2610_005_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1		3															
H2610	005	0	1	01	01	H2610_005_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					39.00	78.00	117.00							97.50																47.00				47.00			1.57	1.30				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			97.50				35.00		35.00
H2610	005	0	1	01	01	H2610_005_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					75.00	150.00	225.00							187.50																100.00				100.00			3.33	2.50				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	005	0	1	01	01	H2610_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00						35.00		35.00
H2610	005	0	1	01	01	H2610_005_0	4			Select Diabetic Drugs	4	11	1	2	6	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2610	006	0	1	01	01	H2610_006_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H2610	006	0	1	01	01	H2610_006_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H2610	006	0	1	01	01	H2610_006_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H2610	006	0	1	01	01	H2610_006_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1		3															
H2610	006	0	1	01	01	H2610_006_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								42.00	84.00	126.00					34.00	68.00	102.00							85.00																42.00				42.00			1.40	1.13				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	34.00	68.00	102.00			85.00				35.00		35.00
H2610	006	0	1	01	01	H2610_006_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								80.00	160.00	240.00					65.00	130.00	195.00							162.50																80.00				80.00			2.67	2.17				2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	006	0	1	01	01	H2610_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00						35.00		35.00
H2610	006	0	1	01	01	H2610_006_0	4			Select Diabetic Drugs	4	11	1	2	6	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2610	006	0	1	01	01	H2610_006_0	4			Select Diabetic Drugs	4	11	1	2	6	3		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H2610	011	0	1	01	01	H2610_011_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								7.00	14.00	21.00					0.00	0.00	0.00							0.00																7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													7.00	14.00	21.00	0.00	0.00	0.00			0.00				7.00		7.00
H2610	011	0	1	01	01	H2610_011_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								7.00	14.00	21.00					0.00	0.00	0.00							0.00																7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H2610	011	0	1	01	01	H2610_011_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H2610	011	0	1	01	01	H2610_011_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1		3															
H2610	011	0	1	01	01	H2610_011_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					42.00	84.00	126.00							105.00																47.00				47.00			1.57	1.40				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	011	0	1	01	01	H2610_011_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								95.00	190.00	285.00					85.00	170.00	255.00							212.50																95.00				95.00			3.17	2.83				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	011	0	1	01	01	H2610_011_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00						35.00		35.00
H2610	011	0	1	01	01	H2610_011_0	4			Select Diabetic Drugs	4	11	1	2	6	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2610	015	0	1	01	01	H2610_015_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	15.00	0.00	0.00	0.00			0.00				5.00		5.00
H2610	015	0	1	01	01	H2610_015_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H2610	015	0	1	01	01	H2610_015_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							12.50																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													10.00	20.00	30.00	5.00	10.00	15.00			12.50				10.00		10.00
H2610	015	0	1	01	01	H2610_015_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							12.50																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1		3															
H2610	015	0	1	01	01	H2610_015_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					42.00	84.00	126.00							105.00																47.00				47.00			1.57	1.40				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	015	0	1	01	01	H2610_015_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	015	0	1	01	01	H2610_015_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00						35.00		35.00
H2610	015	0	1	01	01	H2610_015_0	4			Select Diabetic Drugs	4	11	1	2	6	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2610	016	0	1	01	01	H2610_016_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H2610	016	0	1	01	01	H2610_016_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H2610	016	0	1	01	01	H2610_016_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H2610	016	0	1	01	01	H2610_016_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1		3															
H2610	016	0	1	01	01	H2610_016_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					39.00	78.00	117.00							97.50																47.00				47.00			1.57	1.30				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			97.50				35.00		35.00
H2610	016	0	1	01	01	H2610_016_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					75.00	150.00	225.00							187.50																100.00				100.00			3.33	2.50				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	016	0	1	01	01	H2610_016_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00						35.00		35.00
H2610	016	0	1	01	01	H2610_016_0	4			Select Diabetic Drugs	4	11	1	2	6	1		111	01	100		1				30	60	90	1	2			90				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2610	019	0	1	01	01	H2610_019_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00			0.00				5.00		5.00
H2610	019	0	1	01	01	H2610_019_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H2610	019	0	1	01	01	H2610_019_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			0.00				10.00		10.00
H2610	019	0	1	01	01	H2610_019_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					5.00	10.00	15.00							0.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H2610	019	0	1	01	01	H2610_019_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	019	0	1	01	01	H2610_019_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	019	0	1	01	01	H2610_019_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H2610	021	0	1	01	01	H2610_021_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00			0.00				5.00		5.00
H2610	021	0	1	01	01	H2610_021_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H2610	021	0	1	01	01	H2610_021_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00			0.00				10.00		10.00
H2610	021	0	1	01	01	H2610_021_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H2610	021	0	1	01	01	H2610_021_0	5			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					40.00	80.00	120.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			100.00				35.00		35.00
H2610	021	0	1	01	01	H2610_021_0	5			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	021	0	1	01	01	H2610_021_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H2610	023	0	1	01	01	H2610_023_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00			0.00				5.00		5.00
H2610	023	0	1	01	01	H2610_023_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H2610	023	0	1	01	01	H2610_023_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00			0.00				10.00		10.00
H2610	023	0	1	01	01	H2610_023_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H2610	023	0	1	01	01	H2610_023_0	5			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					40.00	80.00	120.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			100.00				35.00		35.00
H2610	023	0	1	01	01	H2610_023_0	5			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2610	023	0	1	01	01	H2610_023_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H2624	001	0	1	01	01	H2624_001_0	10			Preferred Generic	4	01	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								5.00	10.00	10.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2624	001	0	1	01	01	H2624_001_0	10			Preferred Generic	4	01	3	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								5.00	10.00	10.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2624	001	0	1	01	01	H2624_001_0	10			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								15.00	30.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																	15.00			15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2624	001	0	1	01	01	H2624_001_0	10			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	94.00					47.00	94.00	94.00					47.00	94.00	94.00																	47.00			47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2624	001	0	1	01	01	H2624_001_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	200.00					100.00	200.00	200.00					100.00	200.00	200.00																	100.00			100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2624	001	0	1	01	01	H2624_001_0	10			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											567.13	31	31	31				723.15	31	31	31				31	31	31																31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2624	001	0	1	01	01	H2624_001_0	10			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H2624	001	0	1	01	01	H2624_001_0	10			Select Care Drugs	4	11	1	2	6	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H2624	004	0	1	01	01	H2624_004_0	11			Preferred Generic	4	01	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																	10.00			10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2624	004	0	1	01	01	H2624_004_0	11			Preferred Generic	4	01	3	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																	10.00			10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2624	004	0	1	01	01	H2624_004_0	11			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								20.00	40.00	40.00					5.00	10.00	10.00					5.00	10.00	10.00																	20.00			20.00			0.67	0.17	0.17			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2624	004	0	1	01	01	H2624_004_0	11			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	94.00					47.00	94.00	94.00					47.00	94.00	94.00																	47.00			47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	94.00	35.00	70.00	94.00	35.00	70.00	94.00				35.00		35.00
H2624	004	0	1	01	01	H2624_004_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	200.00					100.00	200.00	200.00					100.00	200.00	200.00																	100.00			100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2624	004	0	1	01	01	H2624_004_0	11			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											616.01	33	33	33				753.15	33	33	33				33	33	33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	002	0	1	01	01	H2663_002_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	002	0	1	01	01	H2663_002_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2663	002	0	1	01	01	H2663_002_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	002	0	1	01	01	H2663_002_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2663	002	0	1	01	01	H2663_002_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	002	0	1	01	01	H2663_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	002	0	1	01	01	H2663_002_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											722.23	33						502.59	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	005	0	1	01	01	H2663_005_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	005	0	1	01	01	H2663_005_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	005	0	1	01	01	H2663_005_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	005	0	1	01	01	H2663_005_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	005	0	1	01	01	H2663_005_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	005	0	1	01	01	H2663_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	005	0	1	01	01	H2663_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											718.75	33						766.49	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	006	0	1	02	01	H2663_006_0	9			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	006	0	1	02	01	H2663_006_0	9			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2663	006	0	1	02	01	H2663_006_0	9			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	006	0	1	02	01	H2663_006_0	9			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2663	006	0	1	02	01	H2663_006_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	006	0	1	02	01	H2663_006_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	006	0	1	02	01	H2663_006_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											831.43	33						598.02	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	017	0	1	01	01	H2663_017_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	017	0	1	01	01	H2663_017_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	017	0	1	01	01	H2663_017_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	017	0	1	01	01	H2663_017_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	017	0	1	01	01	H2663_017_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	017	0	1	01	01	H2663_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	017	0	1	01	01	H2663_017_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											877.66	33						677.44	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	021	0	1	02	01	H2663_021_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	021	0	1	02	01	H2663_021_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	021	0	1	02	01	H2663_021_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	021	0	1	02	01	H2663_021_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	021	0	1	02	01	H2663_021_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	021	0	1	02	01	H2663_021_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	021	0	1	02	01	H2663_021_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											783.74	33						745.33	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	023	0	1	02	01	H2663_023_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	023	0	1	02	01	H2663_023_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	023	0	1	02	01	H2663_023_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	023	0	1	02	01	H2663_023_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	023	0	1	02	01	H2663_023_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	023	0	1	02	01	H2663_023_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	023	0	1	02	01	H2663_023_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											822.49	33						824.12	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	026	0	1	02	01	H2663_026_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	026	0	1	02	01	H2663_026_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	026	0	1	02	01	H2663_026_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	026	0	1	02	01	H2663_026_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	026	0	1	02	01	H2663_026_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	026	0	1	02	01	H2663_026_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	026	0	1	02	01	H2663_026_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											832.72	33						603.64	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	028	0	1	02	01	H2663_028_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	028	0	1	02	01	H2663_028_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	028	0	1	02	01	H2663_028_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	028	0	1	02	01	H2663_028_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	028	0	1	02	01	H2663_028_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	028	0	1	02	01	H2663_028_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	028	0	1	02	01	H2663_028_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											791.27	33						628.26	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	029	0	1	02	01	H2663_029_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	029	0	1	02	01	H2663_029_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	029	0	1	02	01	H2663_029_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	029	0	1	02	01	H2663_029_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	029	0	1	02	01	H2663_029_0	4			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	029	0	1	02	01	H2663_029_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	029	0	1	02	01	H2663_029_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											859.13	33						708.82	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	034	0	1	01	01	H2663_034_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	034	0	1	01	01	H2663_034_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	034	0	1	01	01	H2663_034_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	034	0	1	01	01	H2663_034_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	034	0	1	01	01	H2663_034_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	034	0	1	01	01	H2663_034_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	034	0	1	01	01	H2663_034_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											773.75	30						625.78	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	038	0	1	01	01	H2663_038_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	038	0	1	01	01	H2663_038_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	038	0	1	01	01	H2663_038_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	038	0	1	01	01	H2663_038_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	038	0	1	01	01	H2663_038_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	038	0	1	01	01	H2663_038_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	038	0	1	01	01	H2663_038_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											867.22	33						713.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	039	0	1	01	01	H2663_039_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	039	0	1	01	01	H2663_039_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00					3.00			3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	039	0	1	01	01	H2663_039_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	039	0	1	01	01	H2663_039_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00					7.00			7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	039	0	1	01	01	H2663_039_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	039	0	1	01	01	H2663_039_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	039	0	1	01	01	H2663_039_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											752.99	33						627.21	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	040	0	1	01	01	H2663_040_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	040	0	1	01	01	H2663_040_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	040	0	1	01	01	H2663_040_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	040	0	1	01	01	H2663_040_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	040	0	1	01	01	H2663_040_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	040	0	1	01	01	H2663_040_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	040	0	1	01	01	H2663_040_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											833.78	33						706.27	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	041	0	1	01	01	H2663_041_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	041	0	1	01	01	H2663_041_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	041	0	1	01	01	H2663_041_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	041	0	1	01	01	H2663_041_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	041	0	1	01	01	H2663_041_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	041	0	1	01	01	H2663_041_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	041	0	1	01	01	H2663_041_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											824.29	33						662.93	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	042	0	1	01	01	H2663_042_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	042	0	1	01	01	H2663_042_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	042	0	1	01	01	H2663_042_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	042	0	1	01	01	H2663_042_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	042	0	1	01	01	H2663_042_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	042	0	1	01	01	H2663_042_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	042	0	1	01	01	H2663_042_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											810.26	33						663.24	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	043	0	1	02	01	H2663_043_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	043	0	1	02	01	H2663_043_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	043	0	1	02	01	H2663_043_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	043	0	1	02	01	H2663_043_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	043	0	1	02	01	H2663_043_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	043	0	1	02	01	H2663_043_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	043	0	1	02	01	H2663_043_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											765.21	33						676.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	052	0	1	01	01	H2663_052_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	052	0	1	01	01	H2663_052_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	052	0	1	01	01	H2663_052_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	052	0	1	01	01	H2663_052_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	052	0	1	01	01	H2663_052_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.21	25	25	25				96.36	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	052	0	1	01	01	H2663_052_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.72	50	50	50				50.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	052	0	1	01	01	H2663_052_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.31	29						625.07	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	053	0	1	01	01	H2663_053_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	053	0	1	01	01	H2663_053_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	053	0	1	01	01	H2663_053_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	053	0	1	01	01	H2663_053_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	053	0	1	01	01	H2663_053_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.21	25	25	25				96.36	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	053	0	1	01	01	H2663_053_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.72	50	50	50				50.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	053	0	1	01	01	H2663_053_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.31	29						625.07	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	054	0	1	01	01	H2663_054_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	054	0	1	01	01	H2663_054_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	054	0	1	01	01	H2663_054_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	054	0	1	01	01	H2663_054_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	054	0	1	01	01	H2663_054_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.21	25	25	25				96.36	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	054	0	1	01	01	H2663_054_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.72	50	50	50				50.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	054	0	1	01	01	H2663_054_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.31	29						625.07	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	055	0	1	01	01	H2663_055_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	055	0	1	01	01	H2663_055_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	055	0	1	01	01	H2663_055_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	055	0	1	01	01	H2663_055_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	055	0	1	01	01	H2663_055_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.21	25	25	25				96.36	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	055	0	1	01	01	H2663_055_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.72	50	50	50				50.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	055	0	1	01	01	H2663_055_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.31	29						625.07	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	056	0	1	01	01	H2663_056_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	056	0	1	01	01	H2663_056_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	056	0	1	01	01	H2663_056_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	056	0	1	01	01	H2663_056_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	056	0	1	01	01	H2663_056_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.21	25	25	25				96.36	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	056	0	1	01	01	H2663_056_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.72	50	50	50				50.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	056	0	1	01	01	H2663_056_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.31	29						625.07	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	057	0	1	01	01	H2663_057_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	057	0	1	01	01	H2663_057_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	057	0	1	01	01	H2663_057_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	057	0	1	01	01	H2663_057_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	057	0	1	01	01	H2663_057_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.02	25	25	25				61.94	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	057	0	1	01	01	H2663_057_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.15	40	40	40				77.92	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	057	0	1	01	01	H2663_057_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											679.48	29						638.17	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	059	0	1	01	01	H2663_059_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	059	0	1	01	01	H2663_059_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	059	0	1	01	01	H2663_059_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	059	0	1	01	01	H2663_059_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	059	0	1	01	01	H2663_059_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.16	25	25	25				74.46	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	059	0	1	01	01	H2663_059_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.52	50	50	50				24.69	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	059	0	1	01	01	H2663_059_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											958.33	33						632.65	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	061	0	1	02	01	H2663_061_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	061	0	1	02	01	H2663_061_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	061	0	1	02	01	H2663_061_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	061	0	1	02	01	H2663_061_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	061	0	1	02	01	H2663_061_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.78	25	25	25				75.42	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	061	0	1	02	01	H2663_061_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.31	50	50	50				25.76	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	061	0	1	02	01	H2663_061_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											929.39	33						644.92	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	062	0	1	02	01	H2663_062_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	062	0	1	02	01	H2663_062_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	062	0	1	02	01	H2663_062_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	062	0	1	02	01	H2663_062_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	062	0	1	02	01	H2663_062_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.62	25	25	25				75.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	062	0	1	02	01	H2663_062_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.23	50	50	50				25.62	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	062	0	1	02	01	H2663_062_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											933.75	33						643.71	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	063	0	1	02	01	H2663_063_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	063	0	1	02	01	H2663_063_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	063	0	1	02	01	H2663_063_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	063	0	1	02	01	H2663_063_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	063	0	1	02	01	H2663_063_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.22	25	25	25				75.05	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	063	0	1	02	01	H2663_063_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.03	50	50	50				25.30	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	063	0	1	02	01	H2663_063_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											944.90	33						640.69	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	064	0	1	01	01	H2663_064_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	064	0	1	01	01	H2663_064_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	064	0	1	01	01	H2663_064_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	064	0	1	01	01	H2663_064_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	064	0	1	01	01	H2663_064_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.21	25	25	25				96.36	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	064	0	1	01	01	H2663_064_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.72	50	50	50				50.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	064	0	1	01	01	H2663_064_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											707.31	29						625.07	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	065	0	1	01	01	H2663_065_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	065	0	1	01	01	H2663_065_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	065	0	1	01	01	H2663_065_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.58	25	25	25				117.55	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	065	0	1	01	01	H2663_065_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.82	40	40	40				42.44	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	065	0	1	01	01	H2663_065_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.12	28						511.80	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	066	0	1	01	01	H2663_066_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	066	0	1	01	01	H2663_066_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	066	0	1	01	01	H2663_066_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.35	25	25	25				119.87	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	066	0	1	01	01	H2663_066_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.04	40	40	40				42.71	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	066	0	1	01	01	H2663_066_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											737.12	28						497.42	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2663	067	0	1	01	01	H2663_067_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	067	0	1	01	01	H2663_067_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	067	0	1	01	01	H2663_067_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	067	0	1	01	01	H2663_067_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2663	067	0	1	01	01	H2663_067_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2663	067	0	1	01	01	H2663_067_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2663	067	0	1	01	01	H2663_067_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											863.62	33						666.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H2686	001	0	1	04	01	H2686_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	001	0	1	04	01	H2686_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2686	001	0	1	04	01	H2686_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	001	0	1	04	01	H2686_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2686	001	0	1	04	01	H2686_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2686	001	0	1	04	01	H2686_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2686	001	0	1	04	01	H2686_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2686	002	0	1	04	01	H2686_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	002	0	1	04	01	H2686_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2686	002	0	1	04	01	H2686_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	002	0	1	04	01	H2686_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2686	002	0	1	04	01	H2686_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2686	002	0	1	04	01	H2686_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2686	002	0	1	04	01	H2686_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2686	003	0	1	04	01	H2686_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2686	003	0	1	04	01	H2686_003_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2686	003	0	1	04	01	H2686_003_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H2686	003	0	1	04	01	H2686_003_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H2686	003	0	1	04	01	H2686_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2686	003	0	1	04	01	H2686_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2686	003	0	1	04	01	H2686_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2694	001	0	1	04	01	H2694_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	001	0	1	04	01	H2694_001_0	5			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		15.00																			5.00		5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	001	0	1	04	01	H2694_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	47.00		141.00																			47.00		47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		35.00				35.00		35.00
H2694	001	0	1	04	01	H2694_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	001	0	1	04	01	H2694_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	002	0	1	04	01	H2694_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	002	0	1	04	01	H2694_002_0	5			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		15.00																			5.00		5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	002	0	1	04	01	H2694_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	47.00		141.00																			47.00		47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		35.00				35.00		35.00
H2694	002	0	1	04	01	H2694_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2694	002	0	1	04	01	H2694_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2697	001	0	1	01	01	H2697_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	001	0	1	01	01	H2697_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	001	0	1	01	01	H2697_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	001	0	1	01	01	H2697_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2697	001	0	1	01	01	H2697_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	001	0	1	01	01	H2697_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	001	0	1	01	01	H2697_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	002	0	1	01	01	H2697_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	002	0	1	01	01	H2697_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	002	0	1	01	01	H2697_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	002	0	1	01	01	H2697_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2697	002	0	1	01	01	H2697_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	002	0	1	01	01	H2697_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	002	0	1	01	01	H2697_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	003	0	1	01	01	H2697_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	003	0	1	01	01	H2697_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	003	0	1	01	01	H2697_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	25.00				10.00		10.00
H2697	003	0	1	01	01	H2697_003_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H2697	003	0	1	01	01	H2697_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	003	0	1	01	01	H2697_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	003	0	1	01	01	H2697_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	004	0	1	01	01	H2697_004_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	004	0	1	01	01	H2697_004_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	004	0	1	01	01	H2697_004_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	004	0	1	01	01	H2697_004_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2697	004	0	1	01	01	H2697_004_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	004	0	1	01	01	H2697_004_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	004	0	1	01	01	H2697_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	005	0	1	01	01	H2697_005_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	005	0	1	01	01	H2697_005_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	005	0	1	01	01	H2697_005_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	005	0	1	01	01	H2697_005_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2697	005	0	1	01	01	H2697_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	005	0	1	01	01	H2697_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	005	0	1	01	01	H2697_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	006	0	1	01	01	H2697_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	006	0	1	01	01	H2697_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	006	0	1	01	01	H2697_006_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	25.00				10.00		10.00
H2697	006	0	1	01	01	H2697_006_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H2697	006	0	1	01	01	H2697_006_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	006	0	1	01	01	H2697_006_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	006	0	1	01	01	H2697_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	007	0	1	01	01	H2697_007_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	007	0	1	01	01	H2697_007_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	007	0	1	01	01	H2697_007_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	007	0	1	01	01	H2697_007_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2697	007	0	1	01	01	H2697_007_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	007	0	1	01	01	H2697_007_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	007	0	1	01	01	H2697_007_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	008	0	1	01	01	H2697_008_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	008	0	1	01	01	H2697_008_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	008	0	1	01	01	H2697_008_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	008	0	1	01	01	H2697_008_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2697	008	0	1	01	01	H2697_008_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	008	0	1	01	01	H2697_008_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	008	0	1	01	01	H2697_008_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2697	009	0	1	01	01	H2697_009_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2697	009	0	1	01	01	H2697_009_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2697	009	0	1	01	01	H2697_009_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	25.00				10.00		10.00
H2697	009	0	1	01	01	H2697_009_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H2697	009	0	1	01	01	H2697_009_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	009	0	1	01	01	H2697_009_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2697	009	0	1	01	01	H2697_009_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2715	001	0	1	01	01	H2715_001_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2715	001	0	1	01	01	H2715_001_0	6			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2715	001	0	1	01	01	H2715_001_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H2715	001	0	1	01	01	H2715_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2715	001	0	1	01	01	H2715_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1129.43	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H2715	001	0	1	01	01	H2715_001_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2722	002	0	1	02	01	H2722_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	002	0	1	02	01	H2722_002_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2722	002	0	1	02	01	H2722_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	002	0	1	02	01	H2722_002_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2722	002	0	1	02	01	H2722_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2722	002	0	1	02	01	H2722_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2722	002	0	1	02	01	H2722_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											796.41	33						441.11	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	004	0	1	02	01	H2722_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	004	0	1	02	01	H2722_004_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2722	004	0	1	02	01	H2722_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	004	0	1	02	01	H2722_004_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2722	004	0	1	02	01	H2722_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H2722	004	0	1	02	01	H2722_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H2722	004	0	1	02	01	H2722_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											895.22	33						682.06	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	005	0	1	02	01	H2722_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	005	0	1	02	01	H2722_005_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2722	005	0	1	02	01	H2722_005_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2722	005	0	1	02	01	H2722_005_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2722	005	0	1	02	01	H2722_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H2722	005	0	1	02	01	H2722_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H2722	005	0	1	02	01	H2722_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											692.92	29						353.81	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2737	001	0	1	04	01	H2737_001_0	7			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2737	001	0	1	04	01	H2737_001_0	7			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								10.00	20.00	30.00					5.00	10.00	15.00													20.00						10.00				10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			20.00			10.00	10.00		10.00
H2737	001	0	1	04	01	H2737_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	90	1	2						90	30		31								45.00	90.00	135.00					40.00	80.00	120.00													90.00						80.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H2737	001	0	1	04	01	H2737_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	90	1	2						90	30		31								95.00	190.00	285.00					90.00	180.00	270.00													285.00						270.00				95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H2737	001	0	1	04	01	H2737_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	26						1.00	26																							26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2737	002	0	1	04	01	H2737_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2737	002	0	1	04	01	H2737_002_0	7			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								10.00	20.00	30.00					5.00	10.00	15.00													20.00						10.00				10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			20.00			10.00	10.00		10.00
H2737	002	0	1	04	01	H2737_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	90	1	2						90	30		31								45.00	90.00	135.00					40.00	80.00	120.00													90.00						80.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H2737	002	0	1	04	01	H2737_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	90	1	2						90	30		31								95.00	190.00	285.00					90.00	180.00	270.00													285.00						270.00				95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H2737	002	0	1	04	01	H2737_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	28						1.00	28																							28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2765	002	0	1	02	01	H2765_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H2765	002	0	1	02	01	H2765_002_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H2765	002	0	1	02	01	H2765_002_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H2765	002	0	1	02	01	H2765_002_0	8			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2765	002	0	1	02	01	H2765_002_0	8			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											230.00	24						200.00	24						24																	24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	002	0	1	02	01	H2765_002_0	8			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	29						250.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	002	0	1	02	01	H2765_002_0	8			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	003	0	1	02	01	H2765_003_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H2765	003	0	1	02	01	H2765_003_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H2765	003	0	1	02	01	H2765_003_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H2765	003	0	1	02	01	H2765_003_0	8			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2765	003	0	1	02	01	H2765_003_0	8			Preferred Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											280.00	25						250.00	25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	003	0	1	02	01	H2765_003_0	8			Specialty Tier	4	11	1	1	6	1		010	01	000		1				30											30		31											280.00	30						250.00	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	003	0	1	02	01	H2765_003_0	8			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	004	0	1	02	01	H2765_004_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H2765	004	0	1	02	01	H2765_004_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H2765	004	0	1	02	01	H2765_004_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H2765	004	0	1	02	01	H2765_004_0	7			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H2765	004	0	1	02	01	H2765_004_0	7			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											280.00	26						230.00	26						26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	004	0	1	02	01	H2765_004_0	7			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											250.00	31						200.00	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2765	004	0	1	02	01	H2765_004_0	7			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H2775	105	0	1	04	01	H2775_105_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	105	0	1	04	01	H2775_105_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	105	0	1	04	01	H2775_105_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2775	105	0	1	04	01	H2775_105_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.55	50	50	50				89.55	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2775	105	0	1	04	01	H2775_105_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2775	105	0	1	04	01	H2775_105_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	106	0	1	04	01	H2775_106_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	106	0	1	04	01	H2775_106_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	106	0	1	04	01	H2775_106_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2775	106	0	1	04	01	H2775_106_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											93.75	50	50	50				93.75	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2775	106	0	1	04	01	H2775_106_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2775	106	0	1	04	01	H2775_106_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	106	0	1	04	01	H2775_106_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2775	109	0	1	04	01	H2775_109_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	109	0	1	04	01	H2775_109_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	109	0	1	04	01	H2775_109_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2775	109	0	1	04	01	H2775_109_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.24	50	50	50				90.24	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2775	109	0	1	04	01	H2775_109_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2775	109	0	1	04	01	H2775_109_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	111	0	1	04	01	H2775_111_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	111	0	1	04	01	H2775_111_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	111	0	1	04	01	H2775_111_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2775	111	0	1	04	01	H2775_111_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.20	50	50	50				91.20	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2775	111	0	1	04	01	H2775_111_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2775	111	0	1	04	01	H2775_111_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	113	0	1	04	01	H2775_113_0	16			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	113	0	1	04	01	H2775_113_0	16			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	113	0	1	04	01	H2775_113_0	16			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H2775	113	0	1	04	01	H2775_113_0	16			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.28	46	46	46				99.28	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2775	113	0	1	04	01	H2775_113_0	16			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2775	113	0	1	04	01	H2775_113_0	16			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	114	0	1	04	01	H2775_114_0	5			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	114	0	1	04	01	H2775_114_0	5			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2775	114	0	1	04	01	H2775_114_0	5			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H2775	114	0	1	04	01	H2775_114_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.75	48	48	48				99.75	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2775	114	0	1	04	01	H2775_114_0	5			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2775	114	0	1	04	01	H2775_114_0	5			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2782	002	0	1	01	01	H2782_002_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	002	0	1	01	01	H2782_002_0	8			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2782	002	0	1	01	01	H2782_002_0	8			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			10.00	20.00	25.00																5.00				5.00		0.17			0.33			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	002	0	1	01	01	H2782_002_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	40.00	80.00	120.00																			47.00	94.00	117.50																40.00				40.00		1.33			1.57			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2782	002	0	1	01	01	H2782_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	002	0	1	01	01	H2782_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	004	0	1	01	01	H2782_004_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	004	0	1	01	01	H2782_004_0	8			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2782	004	0	1	01	01	H2782_004_0	8			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			10.00	20.00	25.00																5.00				5.00		0.17			0.33			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	004	0	1	01	01	H2782_004_0	8			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	40.00	80.00	120.00																			47.00	94.00	117.50																40.00				40.00		1.33			1.57			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2782	004	0	1	01	01	H2782_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2782	004	0	1	01	01	H2782_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	001	0	1	02	01	H2802_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	001	0	1	02	01	H2802_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	001	0	1	02	01	H2802_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	001	0	1	02	01	H2802_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	001	0	1	02	01	H2802_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	001	0	1	02	01	H2802_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	001	0	1	02	01	H2802_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				524.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	007	0	1	02	01	H2802_007_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	007	0	1	02	01	H2802_007_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	007	0	1	02	01	H2802_007_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	007	0	1	02	01	H2802_007_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	007	0	1	02	01	H2802_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	007	0	1	02	01	H2802_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	007	0	1	02	01	H2802_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				541.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	008	0	1	02	01	H2802_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	008	0	1	02	01	H2802_008_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	008	0	1	02	01	H2802_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	008	0	1	02	01	H2802_008_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	008	0	1	02	01	H2802_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	008	0	1	02	01	H2802_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	008	0	1	02	01	H2802_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				492.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	010	0	1	02	01	H2802_010_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	010	0	1	02	01	H2802_010_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	010	0	1	02	01	H2802_010_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	010	0	1	02	01	H2802_010_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	010	0	1	02	01	H2802_010_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	010	0	1	02	01	H2802_010_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	010	0	1	02	01	H2802_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				499.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	012	0	1	02	01	H2802_012_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	012	0	1	02	01	H2802_012_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	012	0	1	02	01	H2802_012_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	012	0	1	02	01	H2802_012_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	012	0	1	02	01	H2802_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	012	0	1	02	01	H2802_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	012	0	1	02	01	H2802_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				600.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	016	0	1	02	01	H2802_016_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	016	0	1	02	01	H2802_016_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	016	0	1	02	01	H2802_016_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	016	0	1	02	01	H2802_016_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	016	0	1	02	01	H2802_016_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	016	0	1	02	01	H2802_016_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	016	0	1	02	01	H2802_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				562.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	018	0	1	02	01	H2802_018_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	018	0	1	02	01	H2802_018_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	018	0	1	02	01	H2802_018_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	018	0	1	02	01	H2802_018_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	018	0	1	02	01	H2802_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	018	0	1	02	01	H2802_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	018	0	1	02	01	H2802_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				354.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	024	0	1	02	01	H2802_024_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	024	0	1	02	01	H2802_024_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	024	0	1	02	01	H2802_024_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	024	0	1	02	01	H2802_024_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	024	0	1	02	01	H2802_024_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	024	0	1	02	01	H2802_024_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	024	0	1	02	01	H2802_024_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				494.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	025	0	1	02	01	H2802_025_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	025	0	1	02	01	H2802_025_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	025	0	1	02	01	H2802_025_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	025	0	1	02	01	H2802_025_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	025	0	1	02	01	H2802_025_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	025	0	1	02	01	H2802_025_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	025	0	1	02	01	H2802_025_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	028	0	1	02	01	H2802_028_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	028	0	1	02	01	H2802_028_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	028	0	1	02	01	H2802_028_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	6.00		12.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	028	0	1	02	01	H2802_028_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	6.00		12.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	028	0	1	02	01	H2802_028_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	028	0	1	02	01	H2802_028_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	028	0	1	02	01	H2802_028_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				513.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	029	0	1	02	01	H2802_029_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	029	0	1	02	01	H2802_029_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	029	0	1	02	01	H2802_029_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	029	0	1	02	01	H2802_029_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	029	0	1	02	01	H2802_029_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	029	0	1	02	01	H2802_029_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	029	0	1	02	01	H2802_029_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				643.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	030	0	1	02	01	H2802_030_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	030	0	1	02	01	H2802_030_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	030	0	1	02	01	H2802_030_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	030	0	1	02	01	H2802_030_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	030	0	1	02	01	H2802_030_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	030	0	1	02	01	H2802_030_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	030	0	1	02	01	H2802_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				624.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	031	0	1	02	01	H2802_031_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	031	0	1	02	01	H2802_031_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	031	0	1	02	01	H2802_031_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	031	0	1	02	01	H2802_031_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	031	0	1	02	01	H2802_031_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	031	0	1	02	01	H2802_031_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	031	0	1	02	01	H2802_031_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				549.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	032	0	1	02	01	H2802_032_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	032	0	1	02	01	H2802_032_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	032	0	1	02	01	H2802_032_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	032	0	1	02	01	H2802_032_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	032	0	1	02	01	H2802_032_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	032	0	1	02	01	H2802_032_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	032	0	1	02	01	H2802_032_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				615.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	033	0	1	02	01	H2802_033_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	033	0	1	02	01	H2802_033_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	033	0	1	02	01	H2802_033_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	033	0	1	02	01	H2802_033_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	033	0	1	02	01	H2802_033_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	033	0	1	02	01	H2802_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	033	0	1	02	01	H2802_033_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				513.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	034	0	1	02	01	H2802_034_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	034	0	1	02	01	H2802_034_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	034	0	1	02	01	H2802_034_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	034	0	1	02	01	H2802_034_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	034	0	1	02	01	H2802_034_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	034	0	1	02	01	H2802_034_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	034	0	1	02	01	H2802_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				339.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	035	0	1	02	01	H2802_035_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	035	0	1	02	01	H2802_035_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	035	0	1	02	01	H2802_035_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	035	0	1	02	01	H2802_035_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	035	0	1	02	01	H2802_035_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	035	0	1	02	01	H2802_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	035	0	1	02	01	H2802_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				621.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	041	0	1	02	01	H2802_041_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	041	0	1	02	01	H2802_041_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	041	0	1	02	01	H2802_041_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	041	0	1	02	01	H2802_041_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	041	0	1	02	01	H2802_041_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	041	0	1	02	01	H2802_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	041	0	1	02	01	H2802_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				536.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	048	0	1	02	01	H2802_048_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	048	0	1	02	01	H2802_048_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	048	0	1	02	01	H2802_048_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	048	0	1	02	01	H2802_048_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	048	0	1	02	01	H2802_048_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	048	0	1	02	01	H2802_048_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	048	0	1	02	01	H2802_048_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				425.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	049	0	1	02	01	H2802_049_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	049	0	1	02	01	H2802_049_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	049	0	1	02	01	H2802_049_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	049	0	1	02	01	H2802_049_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	049	0	1	02	01	H2802_049_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	049	0	1	02	01	H2802_049_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	049	0	1	02	01	H2802_049_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				569.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	052	0	1	02	01	H2802_052_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	052	0	1	02	01	H2802_052_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	052	0	1	02	01	H2802_052_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	052	0	1	02	01	H2802_052_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	052	0	1	02	01	H2802_052_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	052	0	1	02	01	H2802_052_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	052	0	1	02	01	H2802_052_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				814.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	054	0	1	02	01	H2802_054_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	054	0	1	02	01	H2802_054_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	054	0	1	02	01	H2802_054_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	054	0	1	02	01	H2802_054_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	054	0	1	02	01	H2802_054_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	054	0	1	02	01	H2802_054_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	054	0	1	02	01	H2802_054_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				508.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	055	0	1	02	01	H2802_055_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	055	0	1	02	01	H2802_055_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	055	0	1	02	01	H2802_055_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	055	0	1	02	01	H2802_055_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	055	0	1	02	01	H2802_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	055	0	1	02	01	H2802_055_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	055	0	1	02	01	H2802_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	056	0	1	02	01	H2802_056_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	056	0	1	02	01	H2802_056_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	056	0	1	02	01	H2802_056_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	056	0	1	02	01	H2802_056_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	056	0	1	02	01	H2802_056_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	056	0	1	02	01	H2802_056_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	056	0	1	02	01	H2802_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				499.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	057	0	1	02	01	H2802_057_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	057	0	1	02	01	H2802_057_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	057	0	1	02	01	H2802_057_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	057	0	1	02	01	H2802_057_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	057	0	1	02	01	H2802_057_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	057	0	1	02	01	H2802_057_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	057	0	1	02	01	H2802_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				332.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	058	0	1	02	01	H2802_058_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	058	0	1	02	01	H2802_058_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	058	0	1	02	01	H2802_058_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	058	0	1	02	01	H2802_058_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	058	0	1	02	01	H2802_058_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	058	0	1	02	01	H2802_058_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	058	0	1	02	01	H2802_058_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				277.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	059	0	1	02	01	H2802_059_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	059	0	1	02	01	H2802_059_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	059	0	1	02	01	H2802_059_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	059	0	1	02	01	H2802_059_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	059	0	1	02	01	H2802_059_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	059	0	1	02	01	H2802_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	059	0	1	02	01	H2802_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				277.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	060	0	1	02	01	H2802_060_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	060	0	1	02	01	H2802_060_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	060	0	1	02	01	H2802_060_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	060	0	1	02	01	H2802_060_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	060	0	1	02	01	H2802_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	060	0	1	02	01	H2802_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	060	0	1	02	01	H2802_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				551.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	061	0	1	02	01	H2802_061_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	061	0	1	02	01	H2802_061_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	061	0	1	02	01	H2802_061_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	061	0	1	02	01	H2802_061_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	061	0	1	02	01	H2802_061_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	061	0	1	02	01	H2802_061_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	061	0	1	02	01	H2802_061_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				486.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	063	0	1	02	01	H2802_063_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	063	0	1	02	01	H2802_063_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2802	063	0	1	02	01	H2802_063_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2802	063	0	1	02	01	H2802_063_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H2802	063	0	1	02	01	H2802_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	063	0	1	02	01	H2802_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H2802	063	0	1	02	01	H2802_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				371.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2816	013	0	1	09	04	H2816_013_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2816	013	0	1	09	04	H2816_013_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2816	013	0	1	09	04	H2816_013_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2816	013	0	1	09	04	H2816_013_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.64	50	50	50				85.64	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2816	013	0	1	09	04	H2816_013_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2816	013	0	1	09	04	H2816_013_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2816	019	0	1	09	04	H2816_019_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2816	019	0	1	09	04	H2816_019_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2816	019	0	1	09	04	H2816_019_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2816	019	0	1	09	04	H2816_019_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.68	50	50	50				89.68	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2816	019	0	1	09	04	H2816_019_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2816	019	0	1	09	04	H2816_019_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2819	001	0	1	01	01	H2819_001_0	5		N	Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	001	0	1	01	01	H2819_001_0	5		N	Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2819	001	0	1	01	01	H2819_001_0	5		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	90				2	2			90				30		31				4.70	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	001	0	1	01	01	H2819_001_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				104.33	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2819	001	0	1	01	01	H2819_001_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				92.88	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2819	001	0	1	01	01	H2819_001_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				801.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	002	0	1	01	01	H2819_002_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	002	0	1	01	01	H2819_002_0	6		N	Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2819	002	0	1	01	01	H2819_002_0	6		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	90				2	2			90				30		31				4.33	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	002	0	1	01	01	H2819_002_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				102.35	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2819	002	0	1	01	01	H2819_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				87.22	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2819	002	0	1	01	01	H2819_002_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				881.74	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	003	0	1	01	01	H2819_003_0	5		N	Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	003	0	1	01	01	H2819_003_0	5		N	Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H2819	003	0	1	01	01	H2819_003_0	5		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	90				2	2			90				30		31				4.75	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2819	003	0	1	01	01	H2819_003_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				104.93	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2819	003	0	1	01	01	H2819_003_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				93.55	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H2819	003	0	1	01	01	H2819_003_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				808.12	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2836	005	0	1	04	01	H2836_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2836	005	0	1	04	01	H2836_005_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2836	005	0	1	04	01	H2836_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H2836	005	0	1	04	01	H2836_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2836	005	0	1	04	01	H2836_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2836	005	0	1	04	01	H2836_005_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2836	005	0	1	04	01	H2836_005_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2879	002	0	1	01	01	H2879_002_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	002	0	1	01	01	H2879_002_0	6			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	002	0	1	01	01	H2879_002_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				30.00	70.00	94.00				35.00		35.00
H2879	002	0	1	01	01	H2879_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	002	0	1	01	01	H2879_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1085.37	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H2879	002	0	1	01	01	H2879_002_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	003	0	1	01	01	H2879_003_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	003	0	1	01	01	H2879_003_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	003	0	1	01	01	H2879_003_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H2879	003	0	1	01	01	H2879_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	003	0	1	01	01	H2879_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				995.52	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H2879	003	0	1	01	01	H2879_003_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	004	0	1	01	01	H2879_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	004	0	1	01	01	H2879_004_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	20.00	40.00	60.00																			20.00	40.00	40.00																20.00				20.00		0.65			0.65			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	004	0	1	01	01	H2879_004_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H2879	004	0	1	01	01	H2879_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2879	004	0	1	01	01	H2879_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1021.31	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H2879	004	0	1	01	01	H2879_004_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	003	0	1	01	01	H2915_003_0	5			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	003	0	1	01	01	H2915_003_0	5			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2915	003	0	1	01	01	H2915_003_0	5			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	003	0	1	01	01	H2915_003_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2915	003	0	1	01	01	H2915_003_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.05	50	50	50				86.05	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2915	003	0	1	01	01	H2915_003_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2915	003	0	1	01	01	H2915_003_0	5			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	003	0	1	01	01	H2915_003_0	5			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H2915	011	0	1	01	01	H2915_011_0	5			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	011	0	1	01	01	H2915_011_0	5			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	011	0	1	01	01	H2915_011_0	5			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H2915	011	0	1	01	01	H2915_011_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.72	48	48	48				99.72	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2915	011	0	1	01	01	H2915_011_0	5			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2915	011	0	1	01	01	H2915_011_0	5			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	016	0	1	01	01	H2915_016_0	5			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	016	0	1	01	01	H2915_016_0	5			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2915	016	0	1	01	01	H2915_016_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H2915	016	0	1	01	01	H2915_016_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.65	48	48	48				98.65	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H2915	016	0	1	01	01	H2915_016_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H2915	016	0	1	01	01	H2915_016_0	5			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2923	001	0	1	01	01	H2923_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2923	001	0	1	01	01	H2923_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H2923	001	0	1	01	01	H2923_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H2923	001	0	1	01	01	H2923_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H2923	001	0	1	01	01	H2923_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2923	001	0	1	01	01	H2923_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H2923	001	0	1	01	01	H2923_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H2942	001	0	1	01	01	H2942_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	1	2			100				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																0.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H2942	001	0	1	01	01	H2942_001_0	9			Generic	4	01	3	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							25.00																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H2942	001	0	1	01	01	H2942_001_0	9			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	100	1	2			100				30		31								47.00	94.00	141.00					42.00	84.00	126.00							117.50																47.00				47.00			1.57	1.40				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H2942	001	0	1	01	01	H2942_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	100	1	2			100				30		31								100.00	200.00	300.00					95.00	190.00	285.00							250.00																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H2942	001	0	1	01	01	H2942_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1000.00	33						1000.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H2942	001	0	1	01	01	H2942_001_0	9			Select Diabetic Drugs	4	11	1	2	6	1		111	01	100		1				30	60	100	1	2			100				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00	0.00	0.00	0.00			0.00				0.00		0.00
H2944	013	0	1	09	04	H2944_013_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H2944	013	0	1	09	04	H2944_013_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	14.00		42.00																									20.00		60.00				14.00		0.00				14.00				14.00		0.47				0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00		42.00				20.00		60.00	14.00		0.00	14.00		14.00
H2944	013	0	1	09	04	H2944_013_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2944	013	0	1	09	04	H2944_013_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H2944	013	0	1	09	04	H2944_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H2960	012	0	1	01	01	H2960_012_0	6			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31	5.00	10.00	12.50																				10.00	10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	012	0	1	01	01	H2960_012_0	6			Preferred Generic	4	01	1	2	1	3	111		01	101		1	30	60	100				1	2		60	100				30		31	5.00	10.00	12.50																				10.00	10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	012	0	1	01	01	H2960_012_0	6			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31	12.00	24.00	30.00																				24.00	24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	012	0	1	01	01	H2960_012_0	6			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31	47.00	94.00	117.50																				94.00	94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	87.50					70.00	70.00				35.00		35.00
H2960	012	0	1	01	01	H2960_012_0	6			Non-Preferred Drug	4	10	1	2	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31	100.00	200.00	250.00																				200.00	200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	012	0	1	01	01	H2960_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	012	0	1	01	01	H2960_012_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	012	0	1	01	01	H2960_012_0	6			Select Care Drugs	4	01	1	2	6	3	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	018	0	1	01	01	H2960_018_0	6			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	018	0	1	01	01	H2960_018_0	6			Preferred Generic	4	01	1	2	1	3	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	018	0	1	01	01	H2960_018_0	6			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	018	0	1	01	01	H2960_018_0	6			Generic	4	01	1	2	2	3	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	018	0	1	01	01	H2960_018_0	6			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31	47.00	94.00	117.50																				94.00	94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	87.50					70.00	70.00				35.00		35.00
H2960	018	0	1	01	01	H2960_018_0	6			Non-Preferred Drug	4	10	1	2	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31	100.00	200.00	250.00																				200.00	200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	018	0	1	01	01	H2960_018_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	018	0	1	01	01	H2960_018_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	018	0	1	01	01	H2960_018_0	6			Select Care Drugs	4	01	1	2	6	3	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	019	0	1	01	01	H2960_019_0	4			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31	2.00	4.00	5.00																				4.00	4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	019	0	1	01	01	H2960_019_0	4			Preferred Generic	4	01	1	2	1	3	111		01	101		1	30	60	100				1	2		60	100				30		31	2.00	4.00	5.00																				4.00	4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	019	0	1	01	01	H2960_019_0	4			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31	8.00	16.00	20.00																				16.00	16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	019	0	1	01	01	H2960_019_0	4			Generic	4	01	1	2	2	3	111		01	101		1	30	60	100				1	2		60	100				30		31	8.00	16.00	20.00																				16.00	16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	019	0	1	01	01	H2960_019_0	4			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31	47.00	94.00	117.50																				94.00	94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	87.50					70.00	70.00				35.00		35.00
H2960	019	0	1	01	01	H2960_019_0	4			Non-Preferred Drug	4	10	1	2	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31	100.00	200.00	250.00																				200.00	200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	019	0	1	01	01	H2960_019_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	019	0	1	01	01	H2960_019_0	4			Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	019	0	1	01	01	H2960_019_0	4			Select Care Drugs	4	01	1	2	6	3	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	023	0	1	01	01	H2960_023_0	5			Preferred Generic	4	01	1	2	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31	5.00	10.00	12.50																				10.00	10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	023	0	1	01	01	H2960_023_0	5			Preferred Generic	4	01	1	2	1	3	111		01	101		1	30	60	100				1	2		60	100				30		31	5.00	10.00	12.50																				10.00	10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2960	023	0	1	01	01	H2960_023_0	5			Generic	4	01	1	2	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31	12.00	24.00	30.00																				24.00	24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	023	0	1	01	01	H2960_023_0	5			Preferred Brand	4	10	1	2	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31	47.00	94.00	117.50																				94.00	94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	87.50					70.00	70.00				35.00		35.00
H2960	023	0	1	01	01	H2960_023_0	5			Non-Preferred Drug	4	10	1	2	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31	100.00	200.00	250.00																				200.00	200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	023	0	1	01	01	H2960_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	023	0	1	01	01	H2960_023_0	5			Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2960	023	0	1	01	01	H2960_023_0	5			Select Care Drugs	4	01	1	2	6	3	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	001	0	1	01	01	H2962_001_0	8			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H2962	001	0	1	01	01	H2962_001_0	8			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2962	001	0	1	01	01	H2962_001_0	8			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	15.00		45.00																					30.00																15.00				15.00		0.50						0.48	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00						30.00				15.00		15.00
H2962	001	0	1	01	01	H2962_001_0	8			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	001	0	1	01	01	H2962_001_0	8			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	021	0	1	01	01	H2962_021_0	6			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	021	0	1	01	01	H2962_021_0	6			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	021	0	1	01	01	H2962_021_0	6			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	021	0	1	01	01	H2962_021_0	6			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	50.00		150.00																					100.00																50.00				50.00		1.67						1.61	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	021	0	1	01	01	H2962_021_0	6			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	021	0	1	01	01	H2962_021_0	6			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	021	0	1	01	01	H2962_021_0	6			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	022	0	1	01	01	H2962_022_0	6			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	022	0	1	01	01	H2962_022_0	6			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	022	0	1	01	01	H2962_022_0	6			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	022	0	1	01	01	H2962_022_0	6			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	50.00		150.00																					100.00																50.00				50.00		1.67						1.61	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	022	0	1	01	01	H2962_022_0	6			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	022	0	1	01	01	H2962_022_0	6			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	022	0	1	01	01	H2962_022_0	6			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	023	0	1	01	01	H2962_023_0	6			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	023	0	1	01	01	H2962_023_0	6			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	023	0	1	01	01	H2962_023_0	6			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	20.00		60.00																					40.00																20.00				20.00		0.67						0.65	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	023	0	1	01	01	H2962_023_0	6			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	023	0	1	01	01	H2962_023_0	6			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	023	0	1	01	01	H2962_023_0	6			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	023	0	1	01	01	H2962_023_0	6			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	025	0	1	01	01	H2962_025_0	6			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	025	0	1	01	01	H2962_025_0	6			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	025	0	1	01	01	H2962_025_0	6			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	025	0	1	01	01	H2962_025_0	6			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	50.00		150.00																					100.00																50.00				50.00		1.67						1.61	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	025	0	1	01	01	H2962_025_0	6			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	025	0	1	01	01	H2962_025_0	6			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	025	0	1	01	01	H2962_025_0	6			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	026	0	1	01	01	H2962_026_0	7			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	026	0	1	01	01	H2962_026_0	7			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	026	0	1	01	01	H2962_026_0	7			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	15.00		45.00																					30.00																15.00				15.00		0.50						0.48	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	026	0	1	01	01	H2962_026_0	7			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	55.00		165.00																					110.00																55.00				55.00		1.83						1.77	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	026	0	1	01	01	H2962_026_0	7			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	026	0	1	01	01	H2962_026_0	7			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	026	0	1	01	01	H2962_026_0	7			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	028	0	1	01	01	H2962_028_0	8			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H2962	028	0	1	01	01	H2962_028_0	8			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2962	028	0	1	01	01	H2962_028_0	8			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	30.00		90.00																					60.00																30.00				30.00		1.00						0.97	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00						60.00				30.00		30.00
H2962	028	0	1	01	01	H2962_028_0	8			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	028	0	1	01	01	H2962_028_0	8			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	029	0	1	01	01	H2962_029_0	6			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	029	0	1	01	01	H2962_029_0	6			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	029	0	1	01	01	H2962_029_0	6			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	20.00		60.00																					40.00																20.00				20.00		0.67						0.65	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	029	0	1	01	01	H2962_029_0	6			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	029	0	1	01	01	H2962_029_0	6			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	029	0	1	01	01	H2962_029_0	6			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	029	0	1	01	01	H2962_029_0	6			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	033	0	1	01	01	H2962_033_0	6			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	033	0	1	01	01	H2962_033_0	6			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	033	0	1	01	01	H2962_033_0	6			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	20.00		60.00																					40.00																20.00				20.00		0.67						0.65	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	033	0	1	01	01	H2962_033_0	6			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	70.00		210.00																					140.00																70.00				70.00		2.33						2.26	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	033	0	1	01	01	H2962_033_0	6			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	033	0	1	01	01	H2962_033_0	6			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	033	0	1	01	01	H2962_033_0	6			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	035	0	1	01	01	H2962_035_0	8		N	Generic	4	01	1	1	1	1	110		01	100		1	30		100				1	2			100				30		31					25		25																				25															25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00						105.00				35.00		35.00
H2962	035	0	1	01	01	H2962_035_0	8		N	Preferred Brand	4	11	1	1	2	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00						105.00				35.00		35.00
H2962	035	0	1	01	01	H2962_035_0	8		N	Non-Preferred Drug	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H2962	035	0	1	01	01	H2962_035_0	8		N	Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					25																																					25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H2962	035	0	1	01	01	H2962_035_0	8		N	Supplemental Drugs	4	01	2	2	5	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H2962	035	0	1	01	01	H2962_035_0	8		N	Supplemental Drugs	4	01	2	2	5	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H2962	036	0	1	01	01	H2962_036_0	8		N	Generic	4	01	1	1	1	1	110		01	100		1	30		100				1	2			100				30		31					25		25																				25															25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00						105.00				35.00		35.00
H2962	036	0	1	01	01	H2962_036_0	8		N	Preferred Brand	4	11	1	1	2	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00		105.00						105.00				35.00		35.00
H2962	036	0	1	01	01	H2962_036_0	8		N	Non-Preferred Drug	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31					25		25																				25															25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H2962	036	0	1	01	01	H2962_036_0	8		N	Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					25																																					25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H2962	036	0	1	01	01	H2962_036_0	8		N	Supplemental Drugs	4	01	2	2	5	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H2962	036	0	1	01	01	H2962_036_0	8		N	Supplemental Drugs	4	01	2	2	5	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H2962	045	0	1	01	01	H2962_045_0	8			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H2962	045	0	1	01	01	H2962_045_0	8			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2962	045	0	1	01	01	H2962_045_0	8			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	25.00		75.00																					50.00																25.00				25.00		0.83						0.81	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						50.00				25.00		25.00
H2962	045	0	1	01	01	H2962_045_0	8			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	045	0	1	01	01	H2962_045_0	8			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	046	0	1	01	01	H2962_046_0	5			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H2962	046	0	1	01	01	H2962_046_0	5			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2962	046	0	1	01	01	H2962_046_0	5			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	30.00		90.00																					60.00																30.00				30.00		1.00						0.97	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00						60.00				30.00		30.00
H2962	046	0	1	01	01	H2962_046_0	5			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	046	0	1	01	01	H2962_046_0	5			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	047	0	1	01	01	H2962_047_0	7			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H2962	047	0	1	01	01	H2962_047_0	7			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H2962	047	0	1	01	01	H2962_047_0	7			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	35.00		105.00																					70.00																35.00				35.00		1.17						1.13	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						70.00				35.00		35.00
H2962	047	0	1	01	01	H2962_047_0	7			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	85.00		255.00																					170.00																85.00				85.00		2.83						2.74	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	047	0	1	01	01	H2962_047_0	7			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H2962	050	0	1	01	01	H2962_050_0	5			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	050	0	1	01	01	H2962_050_0	5			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	050	0	1	01	01	H2962_050_0	5			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	25.00		75.00																					50.00																25.00				25.00		0.83						0.81	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	050	0	1	01	01	H2962_050_0	5			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	60.00		180.00																					120.00																60.00				60.00		2.00						1.94	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	050	0	1	01	01	H2962_050_0	5			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	050	0	1	01	01	H2962_050_0	5			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	050	0	1	01	01	H2962_050_0	5			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	051	0	1	01	01	H2962_051_0	5			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	051	0	1	01	01	H2962_051_0	5			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	051	0	1	01	01	H2962_051_0	5			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	25.00		75.00																					50.00																25.00				25.00		0.83						0.81	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	051	0	1	01	01	H2962_051_0	5			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	65.00		195.00																					130.00																65.00				65.00		2.17						2.10	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	051	0	1	01	01	H2962_051_0	5			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	051	0	1	01	01	H2962_051_0	5			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	051	0	1	01	01	H2962_051_0	5			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H2962	052	0	1	01	01	H2962_052_0	5			Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H2962	052	0	1	01	01	H2962_052_0	5			Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H2962	052	0	1	01	01	H2962_052_0	5			Preferred Brand	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	25.00		75.00																					50.00																25.00				25.00		0.83						0.81	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	052	0	1	01	01	H2962_052_0	5			Non-Preferred Drug	4	11	1	2	3	1	110		01	100		1	30		90				1	2			90				30		31	70.00		210.00																					140.00																70.00				70.00		2.33						2.26	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	052	0	1	01	01	H2962_052_0	5			Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31					33																																					33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H2962	052	0	1	01	01	H2962_052_0	5			Select Care Drugs	4	11	1	2	5	1	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00						20.00				10.00		10.00
H2962	052	0	1	01	01	H2962_052_0	5			Select Care Drugs	4	11	1	2	5	3	110		01	100		1	30		90				1	2			90				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3041	001	0	1	01	01	H3041_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3041	001	0	1	01	01	H3041_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H3041	001	0	1	01	01	H3041_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3041	001	0	1	01	01	H3041_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H3041	001	0	1	01	01	H3041_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H3041	001	0	1	01	01	H3041_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H3041	001	0	1	01	01	H3041_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3047	001	0	1	04	01	H3047_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3047	001	0	1	04	01	H3047_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3047	001	0	1	04	01	H3047_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H3047	001	0	1	04	01	H3047_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											93.30	50	50	50				93.30	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3047	001	0	1	04	01	H3047_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3047	001	0	1	04	01	H3047_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3047	001	0	1	04	01	H3047_001_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H3047	002	0	1	04	01	H3047_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3047	002	0	1	04	01	H3047_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3047	002	0	1	04	01	H3047_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H3047	002	0	1	04	01	H3047_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.66	50	50	50				83.66	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3047	002	0	1	04	01	H3047_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H3047	002	0	1	04	01	H3047_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3047	002	0	1	04	01	H3047_002_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H3071	002	0	1	01	01	H3071_002_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3071	002	0	1	01	01	H3071_002_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	10.00					0.00	0.00	0.00											17.00	34.00	10.00				0.00	0.00	0.00				0.00				0.00			0.57	0.00		0.57	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3071	002	0	1	01	01	H3071_002_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H3071	002	0	1	01	01	H3071_002_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3071	002	0	1	01	01	H3071_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											766.82	33						766.82	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3080	001	0	1	01	01	H3080_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3080	001	0	1	01	01	H3080_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H3080	001	0	1	01	01	H3080_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3080	001	0	1	01	01	H3080_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H3080	001	0	1	01	01	H3080_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H3080	001	0	1	01	01	H3080_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H3080	001	0	1	01	01	H3080_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H3080	002	0	1	01	01	H3080_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3080	002	0	1	01	01	H3080_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H3080	002	0	1	01	01	H3080_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H3080	002	0	1	01	01	H3080_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H3080	002	0	1	01	01	H3080_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H3080	002	0	1	01	01	H3080_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H3080	002	0	1	01	01	H3080_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H3113	008	0	1	02	01	H3113_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3113	008	0	1	02	01	H3113_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3113	008	0	1	02	01	H3113_008_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3113	008	0	1	02	01	H3113_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3113	008	0	1	02	01	H3113_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3113	008	0	1	02	01	H3113_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				558.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3138	001	0	1	04	01	H3138_001_0	12			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H3138	001	0	1	04	01	H3138_001_0	12			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.66	0.16	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H3138	001	0	1	04	01	H3138_001_0	12			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	001	0	1	04	01	H3138_001_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	001	0	1	04	01	H3138_001_0	12			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	001	0	1	04	01	H3138_001_0	12			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3138	002	0	1	04	01	H3138_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H3138	002	0	1	04	01	H3138_002_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.66	0.16	0.00			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H3138	002	0	1	04	01	H3138_002_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	002	0	1	04	01	H3138_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	002	0	1	04	01	H3138_002_0	7			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3138	002	0	1	04	01	H3138_002_0	7			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3146	001	0	1	02	01	H3146_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	001	0	1	02	01	H3146_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	001	0	1	02	01	H3146_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	001	0	1	02	01	H3146_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	001	0	1	02	01	H3146_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	001	0	1	02	01	H3146_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	001	0	1	02	01	H3146_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											995.37	33						671.55	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	004	0	1	02	01	H3146_004_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	004	0	1	02	01	H3146_004_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	004	0	1	02	01	H3146_004_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	004	0	1	02	01	H3146_004_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	004	0	1	02	01	H3146_004_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	004	0	1	02	01	H3146_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	004	0	1	02	01	H3146_004_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											819.03	33						657.40	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	006	0	1	01	01	H3146_006_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	006	0	1	01	01	H3146_006_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	006	0	1	01	01	H3146_006_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	006	0	1	01	01	H3146_006_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	006	0	1	01	01	H3146_006_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	006	0	1	01	01	H3146_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	006	0	1	01	01	H3146_006_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											735.24	30						645.13	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	007	0	1	02	01	H3146_007_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	007	0	1	02	01	H3146_007_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	007	0	1	02	01	H3146_007_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	007	0	1	02	01	H3146_007_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	007	0	1	02	01	H3146_007_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	007	0	1	02	01	H3146_007_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	007	0	1	02	01	H3146_007_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											870.21	33						661.81	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	011	0	1	01	01	H3146_011_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	011	0	1	01	01	H3146_011_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	011	0	1	01	01	H3146_011_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	011	0	1	01	01	H3146_011_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	011	0	1	01	01	H3146_011_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	011	0	1	01	01	H3146_011_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	011	0	1	01	01	H3146_011_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											666.20	28						632.47	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	012	0	1	01	01	H3146_012_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	012	0	1	01	01	H3146_012_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	012	0	1	01	01	H3146_012_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	012	0	1	01	01	H3146_012_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	012	0	1	01	01	H3146_012_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	012	0	1	01	01	H3146_012_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	012	0	1	01	01	H3146_012_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											641.86	28						592.73	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	013	0	1	01	01	H3146_013_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	013	0	1	01	01	H3146_013_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	013	0	1	01	01	H3146_013_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	013	0	1	01	01	H3146_013_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	013	0	1	01	01	H3146_013_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	013	0	1	01	01	H3146_013_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	013	0	1	01	01	H3146_013_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											644.98	28						600.25	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	014	0	1	02	01	H3146_014_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	014	0	1	02	01	H3146_014_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	014	0	1	02	01	H3146_014_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	014	0	1	02	01	H3146_014_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	014	0	1	02	01	H3146_014_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	014	0	1	02	01	H3146_014_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	014	0	1	02	01	H3146_014_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											961.71	33						763.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3146	020	0	1	02	01	H3146_020_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	020	0	1	02	01	H3146_020_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	020	0	1	02	01	H3146_020_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	020	0	1	02	01	H3146_020_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3146	020	0	1	02	01	H3146_020_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.14	25	25	25				81.86	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3146	020	0	1	02	01	H3146_020_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.38	50	50	50				25.81	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3146	020	0	1	02	01	H3146_020_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											981.39	33						689.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3152	022	0	1	02	01	H3152_022_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	022	0	1	02	01	H3152_022_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	022	0	1	02	01	H3152_022_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	022	0	1	02	01	H3152_022_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	022	0	1	02	01	H3152_022_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3152	022	0	1	02	01	H3152_022_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	022	0	1	02	01	H3152_022_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											827.16	30						592.28	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3152	048	0	1	02	01	H3152_048_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	048	0	1	02	01	H3152_048_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	048	0	1	02	01	H3152_048_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	048	0	1	02	01	H3152_048_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	048	0	1	02	01	H3152_048_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3152	048	0	1	02	01	H3152_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	048	0	1	02	01	H3152_048_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											689.46	30						486.99	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3152	080	0	1	02	01	H3152_080_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	080	0	1	02	01	H3152_080_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	080	0	1	02	01	H3152_080_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	080	0	1	02	01	H3152_080_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	080	0	1	02	01	H3152_080_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3152	080	0	1	02	01	H3152_080_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	080	0	1	02	01	H3152_080_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											851.05	30						551.05	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3152	082	0	1	01	01	H3152_082_0	10			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	082	0	1	01	01	H3152_082_0	10			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	082	0	1	01	01	H3152_082_0	10			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	082	0	1	01	01	H3152_082_0	10			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	082	0	1	01	01	H3152_082_0	10			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3152	082	0	1	01	01	H3152_082_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	082	0	1	01	01	H3152_082_0	10			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											620.80	28						629.56	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3152	084	0	1	01	01	H3152_084_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	084	0	1	01	01	H3152_084_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	084	0	1	01	01	H3152_084_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	084	0	1	01	01	H3152_084_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	084	0	1	01	01	H3152_084_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3152	084	0	1	01	01	H3152_084_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	084	0	1	01	01	H3152_084_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											555.07	30						763.47	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3152	088	0	1	01	01	H3152_088_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	088	0	1	01	01	H3152_088_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	088	0	1	01	01	H3152_088_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	088	0	1	01	01	H3152_088_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3152	088	0	1	01	01	H3152_088_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3152	088	0	1	01	01	H3152_088_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3152	088	0	1	01	01	H3152_088_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											655.10	28						481.28	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3170	003	1	1	01	01	H3170_003_1	4			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	0.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00				4.00	8.00	0.00				4.00		4.00
H3170	003	1	1	01	01	H3170_003_1	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	0.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00				14.00	28.00	0.00				14.00		14.00
H3170	003	1	1	01	01	H3170_003_1	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3170	003	1	1	01	01	H3170_003_1	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3170	003	1	1	01	01	H3170_003_1	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1106.45	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3170	003	2	1	01	01	H3170_003_2	6			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	0.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00				4.00	8.00	0.00				4.00		4.00
H3170	003	2	1	01	01	H3170_003_2	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	0.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00				14.00	28.00	0.00				14.00		14.00
H3170	003	2	1	01	01	H3170_003_2	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3170	003	2	1	01	01	H3170_003_2	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3170	003	2	1	01	01	H3170_003_2	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1106.45	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3186	001	0	1	04	01	H3186_001_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	001	0	1	04	01	H3186_001_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	001	0	1	04	01	H3186_001_0	8			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3186	001	0	1	04	01	H3186_001_0	8			Non-Preferred Drug	4	10	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3186	001	0	1	04	01	H3186_001_0	8			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31												30	30	30					30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	001	0	1	04	01	H3186_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	002	0	1	04	01	H3186_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	002	0	1	04	01	H3186_002_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	002	0	1	04	01	H3186_002_0	8			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3186	002	0	1	04	01	H3186_002_0	8			Non-Preferred Drug	4	10	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3186	002	0	1	04	01	H3186_002_0	8			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31												28	28	28					28	28	28										28	28	28				28	28	28			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3186	002	0	1	04	01	H3186_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3189	001	0	1	01	01	H3189_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00			0.00				5.00		5.00
H3189	001	0	1	01	01	H3189_001_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								5.00	10.00	15.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H3189	001	0	1	01	01	H3189_001_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00			0.00				10.00		10.00
H3189	001	0	1	01	01	H3189_001_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								10.00	20.00	30.00					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H3189	001	0	1	01	01	H3189_001_0	5			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					40.00	80.00	120.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			100.00				35.00		35.00
H3189	001	0	1	01	01	H3189_001_0	5			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H3189	001	0	1	01	01	H3189_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H3192	001	0	1	02	01	H3192_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	001	0	1	02	01	H3192_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	001	0	1	02	01	H3192_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	001	0	1	02	01	H3192_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	001	0	1	02	01	H3192_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	001	0	1	02	01	H3192_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	001	0	1	02	01	H3192_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											785.39	33						697.86	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	002	0	1	02	01	H3192_002_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	002	0	1	02	01	H3192_002_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	002	0	1	02	01	H3192_002_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	002	0	1	02	01	H3192_002_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	002	0	1	02	01	H3192_002_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	002	0	1	02	01	H3192_002_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	002	0	1	02	01	H3192_002_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.34	33						706.99	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	003	0	1	02	01	H3192_003_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	003	0	1	02	01	H3192_003_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	003	0	1	02	01	H3192_003_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	003	0	1	02	01	H3192_003_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	003	0	1	02	01	H3192_003_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	003	0	1	02	01	H3192_003_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	003	0	1	02	01	H3192_003_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											772.73	33						622.99	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	004	0	1	02	01	H3192_004_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	004	0	1	02	01	H3192_004_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	004	0	1	02	01	H3192_004_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	004	0	1	02	01	H3192_004_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	004	0	1	02	01	H3192_004_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	004	0	1	02	01	H3192_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	004	0	1	02	01	H3192_004_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											862.85	33						661.30	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	005	0	1	02	01	H3192_005_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	005	0	1	02	01	H3192_005_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	005	0	1	02	01	H3192_005_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	005	0	1	02	01	H3192_005_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	005	0	1	02	01	H3192_005_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	005	0	1	02	01	H3192_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	005	0	1	02	01	H3192_005_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											814.02	33						656.40	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	006	0	1	02	01	H3192_006_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	006	0	1	02	01	H3192_006_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	006	0	1	02	01	H3192_006_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	006	0	1	02	01	H3192_006_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	006	0	1	02	01	H3192_006_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	006	0	1	02	01	H3192_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	006	0	1	02	01	H3192_006_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1024.32	33						745.81	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	010	0	1	02	01	H3192_010_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	010	0	1	02	01	H3192_010_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	010	0	1	02	01	H3192_010_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	010	0	1	02	01	H3192_010_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	010	0	1	02	01	H3192_010_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	010	0	1	02	01	H3192_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	010	0	1	02	01	H3192_010_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											872.14	33						636.77	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	011	0	1	02	01	H3192_011_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	011	0	1	02	01	H3192_011_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	011	0	1	02	01	H3192_011_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	011	0	1	02	01	H3192_011_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	011	0	1	02	01	H3192_011_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	011	0	1	02	01	H3192_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	011	0	1	02	01	H3192_011_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											875.58	33						640.86	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	012	0	1	02	01	H3192_012_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	012	0	1	02	01	H3192_012_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	012	0	1	02	01	H3192_012_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	012	0	1	02	01	H3192_012_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	012	0	1	02	01	H3192_012_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	012	0	1	02	01	H3192_012_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	012	0	1	02	01	H3192_012_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											885.26	33						667.60	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	013	0	1	02	01	H3192_013_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	013	0	1	02	01	H3192_013_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	013	0	1	02	01	H3192_013_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	013	0	1	02	01	H3192_013_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	013	0	1	02	01	H3192_013_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	013	0	1	02	01	H3192_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	013	0	1	02	01	H3192_013_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											793.75	33						671.39	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	017	0	1	02	01	H3192_017_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	017	0	1	02	01	H3192_017_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	017	0	1	02	01	H3192_017_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	017	0	1	02	01	H3192_017_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	017	0	1	02	01	H3192_017_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	017	0	1	02	01	H3192_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	017	0	1	02	01	H3192_017_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											878.38	33						644.15	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3192	020	0	1	02	01	H3192_020_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	020	0	1	02	01	H3192_020_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	020	0	1	02	01	H3192_020_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	020	0	1	02	01	H3192_020_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3192	020	0	1	02	01	H3192_020_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3192	020	0	1	02	01	H3192_020_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3192	020	0	1	02	01	H3192_020_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											915.45	33						673.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3204	001	0	1	01	01	H3204_001_0	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	001	0	1	01	01	H3204_001_0	7			Preferred Generic	4	01	1	2	1	3	111		01		111	1	30	60	90				2	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3204	001	0	1	01	01	H3204_001_0	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	001	0	1	01	01	H3204_001_0	7			Generic	4	01	1	2	2	3	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3204	001	0	1	01	01	H3204_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3204	001	0	1	01	01	H3204_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	95.00	190.00	285.00																									95.00	190.00	285.00				95.00	190.00	285.00				95.00				95.00		3.17				3.17	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3204	001	0	1	01	01	H3204_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	007	0	1	01	01	H3204_007_0	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	007	0	1	01	01	H3204_007_0	7			Preferred Generic	4	01	1	2	1	3	111		01		111	1	30	60	90				2	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3204	007	0	1	01	01	H3204_007_0	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	007	0	1	01	01	H3204_007_0	7			Generic	4	01	1	2	2	3	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3204	007	0	1	01	01	H3204_007_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3204	007	0	1	01	01	H3204_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	95.00	190.00	285.00																									95.00	190.00	285.00				95.00	190.00	285.00				95.00				95.00		3.17				3.17	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3204	007	0	1	01	01	H3204_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	013	4	1	01	01	H3204_013_4	8		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	013	4	1	01	01	H3204_013_4	8		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	013	4	1	01	01	H3204_013_4	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				70.00	18	18	18																		18	18	18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3204	013	4	1	01	01	H3204_013_4	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				55.00	48	48	48																		48	48	48															48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3204	013	4	1	01	01	H3204_013_4	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	013	5	1	01	01	H3204_013_5	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	013	5	1	01	01	H3204_013_5	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	013	5	1	01	01	H3204_013_5	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				70.00	18	18	18																		18	18	18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3204	013	5	1	01	01	H3204_013_5	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				55.00	48	48	48																		48	48	48															48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3204	013	5	1	01	01	H3204_013_5	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	015	0	1	02	01	H3204_015_0	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	4.00	8.00	12.00																									4.00	8.00	12.00				4.00	8.00	8.00				4.00				4.00		0.13				0.13	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	015	0	1	02	01	H3204_015_0	8			Preferred Generic	4	01	1	2	1	3	111		01		111	1	30	60	90				2	2				30	60	90	30		31	4.00	8.00	12.00																									4.00	8.00	12.00				4.00	8.00	8.00				4.00				4.00		0.13				0.13	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3204	015	0	1	02	01	H3204_015_0	8			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3204	015	0	1	02	01	H3204_015_0	8			Generic	4	01	1	2	2	3	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3204	015	0	1	02	01	H3204_015_0	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3204	015	0	1	02	01	H3204_015_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	95.00	190.00	285.00																									95.00	190.00	285.00				95.00	190.00	285.00				95.00				95.00		3.17				3.17	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3204	015	0	1	02	01	H3204_015_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3206	001	0	1	04	01	H3206_001_0	9			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	4.00	8.00	12.00																									4.00	8.00	12.00				4.00	8.00	8.00				4.00				4.00		0.13				0.13	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3206	001	0	1	04	01	H3206_001_0	9			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				10.00	20.00	20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3206	001	0	1	04	01	H3206_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3206	001	0	1	04	01	H3206_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31	95.00	190.00	285.00																									95.00	190.00	285.00				95.00	190.00	285.00				95.00				95.00		3.17				3.17	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3206	001	0	1	04	01	H3206_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	001	0	1	04	01	H3219_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	001	0	1	04	01	H3219_001_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	001	0	1	04	01	H3219_001_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	001	0	1	04	01	H3219_001_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	001	0	1	04	01	H3219_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3219	001	0	1	04	01	H3219_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	001	0	1	04	01	H3219_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.67	28						540.18	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3219	002	0	1	04	01	H3219_002_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	002	0	1	04	01	H3219_002_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	002	0	1	04	01	H3219_002_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	002	0	1	04	01	H3219_002_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	002	0	1	04	01	H3219_002_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3219	002	0	1	04	01	H3219_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	002	0	1	04	01	H3219_002_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											656.22	30						548.33	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3219	003	0	1	04	01	H3219_003_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	003	0	1	04	01	H3219_003_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	003	0	1	04	01	H3219_003_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	003	0	1	04	01	H3219_003_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	003	0	1	04	01	H3219_003_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3219	003	0	1	04	01	H3219_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	003	0	1	04	01	H3219_003_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											987.44	33						664.47	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3219	004	0	1	04	01	H3219_004_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	004	0	1	04	01	H3219_004_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	004	0	1	04	01	H3219_004_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	004	0	1	04	01	H3219_004_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	004	0	1	04	01	H3219_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3219	004	0	1	04	01	H3219_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	004	0	1	04	01	H3219_004_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1192.81	33						750.75	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3219	007	0	1	04	01	H3219_007_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	007	0	1	04	01	H3219_007_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	007	0	1	04	01	H3219_007_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	007	0	1	04	01	H3219_007_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	007	0	1	04	01	H3219_007_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											100.93	25	25	25				93.51	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3219	007	0	1	04	01	H3219_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.52	40	40	40				38.74	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	007	0	1	04	01	H3219_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											623.67	27						559.10	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3219	008	0	1	04	01	H3219_008_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	008	0	1	04	01	H3219_008_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	008	0	1	04	01	H3219_008_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	008	0	1	04	01	H3219_008_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3219	008	0	1	04	01	H3219_008_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.05	25	25	25				95.07	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3219	008	0	1	04	01	H3219_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.32	40	40	40				41.02	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3219	008	0	1	04	01	H3219_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											761.55	27						547.34	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3239	014	0	1	01	01	H3239_014_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	014	0	1	01	01	H3239_014_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3239	014	0	1	01	01	H3239_014_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	014	0	1	01	01	H3239_014_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3239	014	0	1	01	01	H3239_014_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3239	014	0	1	01	01	H3239_014_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	014	0	1	01	01	H3239_014_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											845.97	33						658.71	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3239	017	0	1	01	01	H3239_017_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	017	0	1	01	01	H3239_017_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3239	017	0	1	01	01	H3239_017_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	017	0	1	01	01	H3239_017_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3239	017	0	1	01	01	H3239_017_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3239	017	0	1	01	01	H3239_017_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	017	0	1	01	01	H3239_017_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											868.17	33						681.76	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3239	020	0	1	01	01	H3239_020_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	020	0	1	01	01	H3239_020_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3239	020	0	1	01	01	H3239_020_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	020	0	1	01	01	H3239_020_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3239	020	0	1	01	01	H3239_020_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3239	020	0	1	01	01	H3239_020_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3239	020	0	1	01	01	H3239_020_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											845.97	33						658.71	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3240	013	0	1	01	01	H3240_013_0	6		N	Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	013	0	1	01	01	H3240_013_0	6		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	013	0	1	01	01	H3240_013_0	6		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3240	013	0	1	01	01	H3240_013_0	6		N	Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	013	0	1	01	01	H3240_013_0	6		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	013	0	1	01	01	H3240_013_0	6		N	Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	017	0	1	02	01	H3240_017_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	017	0	1	02	01	H3240_017_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	017	0	1	02	01	H3240_017_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3240	017	0	1	02	01	H3240_017_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								99.00	198.00	297.00					94.00	188.00	282.00					94.00	282.00	282.00																99.00				99.00			3.30	3.13	3.13			2.91	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	017	0	1	02	01	H3240_017_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	017	0	1	02	01	H3240_017_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	021	0	1	01	01	H3240_021_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	021	0	1	01	01	H3240_021_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	021	0	1	01	01	H3240_021_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3240	021	0	1	01	01	H3240_021_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	021	0	1	01	01	H3240_021_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	021	0	1	01	01	H3240_021_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	022	0	1	01	01	H3240_022_0	5			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	022	0	1	01	01	H3240_022_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	022	0	1	01	01	H3240_022_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H3240	022	0	1	01	01	H3240_022_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	022	0	1	01	01	H3240_022_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	022	0	1	01	01	H3240_022_0	5			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	022	0	1	01	01	H3240_022_0	5			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3240	024	0	1	02	01	H3240_024_0	7		N	Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	024	0	1	02	01	H3240_024_0	7		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								4.00	8.00	12.00					4.00	8.00	12.00					4.00	12.00	12.00																4.00				4.00			0.13	0.13	0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	024	0	1	02	01	H3240_024_0	7		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								43.00	86.00	129.00					43.00	86.00	129.00					43.00	129.00	129.00																43.00				43.00			1.43	1.43	1.43			1.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3240	024	0	1	02	01	H3240_024_0	7		N	Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	024	0	1	02	01	H3240_024_0	7		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3240	024	0	1	02	01	H3240_024_0	7		N	Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3251	002	0	1	01	01	H3251_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3251	002	0	1	01	01	H3251_002_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3251	002	0	1	01	01	H3251_002_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3251	002	0	1	01	01	H3251_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3251	002	0	1	01	01	H3251_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3251	002	0	1	01	01	H3251_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3274	002	0	1	01	01	H3274_002_0	11			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	002	0	1	01	01	H3274_002_0	11			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	002	0	1	01	01	H3274_002_0	11			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3274	002	0	1	01	01	H3274_002_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	002	0	1	01	01	H3274_002_0	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	003	0	1	01	01	H3274_003_0	11			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	003	0	1	01	01	H3274_003_0	11			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	003	0	1	01	01	H3274_003_0	11			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3274	003	0	1	01	01	H3274_003_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	003	0	1	01	01	H3274_003_0	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3274	004	0	1	01	01	H3274_004_0	9			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3274	004	0	1	01	01	H3274_004_0	9			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3274	004	0	1	01	01	H3274_004_0	9			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3274	004	0	1	01	01	H3274_004_0	9			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3274	004	0	1	01	01	H3274_004_0	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3274	004	0	1	01	01	H3274_004_0	9			Select Care Drugs	4	11	1	2	6	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3276	001	0	1	02	01	H3276_001_0	12		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	12.00	18.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	001	0	1	02	01	H3276_001_0	12		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	16.00	32.00	48.00																			16.00	32.00	48.00																16.00				16.00		0.53			0.53			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	001	0	1	02	01	H3276_001_0	12		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3276	001	0	1	02	01	H3276_001_0	12		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	001	0	1	02	01	H3276_001_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3276	001	0	1	02	01	H3276_001_0	12		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	12.00	18.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	003	0	1	02	01	H3276_003_0	11		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	003	0	1	02	01	H3276_003_0	11		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	003	0	1	02	01	H3276_003_0	11		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3276	003	0	1	02	01	H3276_003_0	11		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3276	003	0	1	02	01	H3276_003_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3276	003	0	1	02	01	H3276_003_0	11		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3288	001	0	1	04	01	H3288_001_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	001	0	1	04	01	H3288_001_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	001	0	1	04	01	H3288_001_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	001	0	1	04	01	H3288_001_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	001	0	1	04	01	H3288_001_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	001	0	1	04	01	H3288_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	001	0	1	04	01	H3288_001_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											644.10	28						538.29	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	002	0	1	04	01	H3288_002_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	002	0	1	04	01	H3288_002_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	002	0	1	04	01	H3288_002_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	002	0	1	04	01	H3288_002_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	002	0	1	04	01	H3288_002_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	002	0	1	04	01	H3288_002_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	002	0	1	04	01	H3288_002_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											757.53	28						551.33	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	003	0	1	04	01	H3288_003_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	003	0	1	04	01	H3288_003_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	003	0	1	04	01	H3288_003_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	003	0	1	04	01	H3288_003_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	003	0	1	04	01	H3288_003_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	003	0	1	04	01	H3288_003_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	003	0	1	04	01	H3288_003_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											686.14	28						589.72	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	004	0	1	04	01	H3288_004_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	004	0	1	04	01	H3288_004_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	004	0	1	04	01	H3288_004_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	004	0	1	04	01	H3288_004_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	004	0	1	04	01	H3288_004_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	004	0	1	04	01	H3288_004_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	004	0	1	04	01	H3288_004_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											551.62	28						492.03	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	005	0	1	04	01	H3288_005_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	005	0	1	04	01	H3288_005_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	005	0	1	04	01	H3288_005_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	005	0	1	04	01	H3288_005_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	005	0	1	04	01	H3288_005_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.45	25	25	25				82.99	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	005	0	1	04	01	H3288_005_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.95	50	50	50				27.69	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	005	0	1	04	01	H3288_005_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											957.53	33						704.94	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	006	0	1	04	01	H3288_006_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	006	0	1	04	01	H3288_006_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	006	0	1	04	01	H3288_006_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	006	0	1	04	01	H3288_006_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	006	0	1	04	01	H3288_006_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.79	25	25	25				98.05	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	006	0	1	04	01	H3288_006_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.73	50	50	50				55.54	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	006	0	1	04	01	H3288_006_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.96	29						545.72	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	007	0	1	04	01	H3288_007_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	007	0	1	04	01	H3288_007_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	007	0	1	04	01	H3288_007_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	007	0	1	04	01	H3288_007_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	007	0	1	04	01	H3288_007_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											100.76	25	25	25				93.71	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	007	0	1	04	01	H3288_007_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.62	50	50	50				51.38	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	007	0	1	04	01	H3288_007_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.21	29						541.29	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	008	0	1	04	01	H3288_008_0	11			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	008	0	1	04	01	H3288_008_0	11			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	008	0	1	04	01	H3288_008_0	11			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	008	0	1	04	01	H3288_008_0	11			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	008	0	1	04	01	H3288_008_0	11			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.55	25	25	25				98.89	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	008	0	1	04	01	H3288_008_0	11			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.75	50	50	50				48.52	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	008	0	1	04	01	H3288_008_0	11			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											721.96	29						525.77	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	009	0	1	04	01	H3288_009_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	009	0	1	04	01	H3288_009_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	009	0	1	04	01	H3288_009_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	009	0	1	04	01	H3288_009_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	009	0	1	04	01	H3288_009_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											110.38	25	25	25				97.02	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	009	0	1	04	01	H3288_009_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.35	50	50	50				56.17	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	009	0	1	04	01	H3288_009_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.33	29						595.38	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	011	0	1	04	01	H3288_011_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	011	0	1	04	01	H3288_011_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	011	0	1	04	01	H3288_011_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	011	0	1	04	01	H3288_011_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	011	0	1	04	01	H3288_011_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											97.66	25	25	25				80.83	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	011	0	1	04	01	H3288_011_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.39	50	50	50				23.84	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	011	0	1	04	01	H3288_011_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											821.54	33						636.30	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	016	0	1	04	01	H3288_016_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	016	0	1	04	01	H3288_016_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	016	0	1	04	01	H3288_016_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	016	0	1	04	01	H3288_016_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	016	0	1	04	01	H3288_016_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.03	25	25	25				94.41	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	016	0	1	04	01	H3288_016_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.07	50	50	50				55.27	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	016	0	1	04	01	H3288_016_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											985.47	29						640.12	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	017	0	1	04	01	H3288_017_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	017	0	1	04	01	H3288_017_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	017	0	1	04	01	H3288_017_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	017	0	1	04	01	H3288_017_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	017	0	1	04	01	H3288_017_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	017	0	1	04	01	H3288_017_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	017	0	1	04	01	H3288_017_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											582.39	28						533.44	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	018	0	1	04	01	H3288_018_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	018	0	1	04	01	H3288_018_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	018	0	1	04	01	H3288_018_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	018	0	1	04	01	H3288_018_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	018	0	1	04	01	H3288_018_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	018	0	1	04	01	H3288_018_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	018	0	1	04	01	H3288_018_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											615.35	28						564.15	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	019	0	1	04	01	H3288_019_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	019	0	1	04	01	H3288_019_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	019	0	1	04	01	H3288_019_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	019	0	1	04	01	H3288_019_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	019	0	1	04	01	H3288_019_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	019	0	1	04	01	H3288_019_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	019	0	1	04	01	H3288_019_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											671.08	33						651.72	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	020	0	1	04	01	H3288_020_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	020	0	1	04	01	H3288_020_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	020	0	1	04	01	H3288_020_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	020	0	1	04	01	H3288_020_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	020	0	1	04	01	H3288_020_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	020	0	1	04	01	H3288_020_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	020	0	1	04	01	H3288_020_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											776.58	33						681.02	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	021	0	1	04	01	H3288_021_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	021	0	1	04	01	H3288_021_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	021	0	1	04	01	H3288_021_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	021	0	1	04	01	H3288_021_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	021	0	1	04	01	H3288_021_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.36	25	25	25				81.14	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	021	0	1	04	01	H3288_021_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.91	50	50	50				32.61	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	021	0	1	04	01	H3288_021_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											895.40	33						678.09	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	027	0	1	04	01	H3288_027_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	027	0	1	04	01	H3288_027_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	027	0	1	04	01	H3288_027_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	027	0	1	04	01	H3288_027_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	027	0	1	04	01	H3288_027_0	4			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	027	0	1	04	01	H3288_027_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	027	0	1	04	01	H3288_027_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											912.76	30						903.81	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	031	0	1	04	01	H3288_031_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	031	0	1	04	01	H3288_031_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	031	0	1	04	01	H3288_031_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	031	0	1	04	01	H3288_031_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	031	0	1	04	01	H3288_031_0	4			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	031	0	1	04	01	H3288_031_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	031	0	1	04	01	H3288_031_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											746.16	30						702.25	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	042	0	1	04	01	H3288_042_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	042	0	1	04	01	H3288_042_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	042	0	1	04	01	H3288_042_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	042	0	1	04	01	H3288_042_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	042	0	1	04	01	H3288_042_0	4			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	042	0	1	04	01	H3288_042_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	042	0	1	04	01	H3288_042_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											789.29	30						624.25	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	045	0	1	04	01	H3288_045_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	045	0	1	04	01	H3288_045_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	045	0	1	04	01	H3288_045_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	045	0	1	04	01	H3288_045_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	045	0	1	04	01	H3288_045_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											102.93	25	25	25				93.78	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	045	0	1	04	01	H3288_045_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.87	40	40	40				45.72	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	045	0	1	04	01	H3288_045_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											823.91	27						567.41	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	046	0	1	04	01	H3288_046_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	046	0	1	04	01	H3288_046_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	046	0	1	04	01	H3288_046_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	046	0	1	04	01	H3288_046_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	046	0	1	04	01	H3288_046_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.15	25	25	25				97.90	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	046	0	1	04	01	H3288_046_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.20	50	50	50				51.85	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	046	0	1	04	01	H3288_046_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											947.17	29						629.59	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	047	0	1	04	01	H3288_047_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	047	0	1	04	01	H3288_047_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	047	0	1	04	01	H3288_047_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	047	0	1	04	01	H3288_047_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	047	0	1	04	01	H3288_047_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	047	0	1	04	01	H3288_047_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	047	0	1	04	01	H3288_047_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											878.17	28						560.55	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3288	048	0	1	04	01	H3288_048_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	048	0	1	04	01	H3288_048_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	048	0	1	04	01	H3288_048_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	048	0	1	04	01	H3288_048_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3288	048	0	1	04	01	H3288_048_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3288	048	0	1	04	01	H3288_048_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3288	048	0	1	04	01	H3288_048_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											779.57	28						643.04	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3291	003	0	1	01	01	H3291_003_0	7			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3291	003	0	1	01	01	H3291_003_0	7			Generic	4	01	1	2	2	1	111		10			1	30	60	90				2	2								10	31	7.00	14.00	21.00																																						7.00			7.00		0.23						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3291	003	0	1	01	01	H3291_003_0	7			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				2	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00										35.00		35.00
H3291	003	0	1	01	01	H3291_003_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		10			1	30	60	90				2	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3291	003	0	1	01	01	H3291_003_0	7			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31					33																																						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3305	015	0	1	02	01	H3305_015_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3305	015	0	1	02	01	H3305_015_0	10			Preferred Generic	4	01	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3305	015	0	1	02	01	H3305_015_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H3305	015	0	1	02	01	H3305_015_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	40.00		120.00																			40.00		80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	015	0	1	02	01	H3305_015_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				101.52	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	015	0	1	02	01	H3305_015_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1556.91	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3305	021	0	1	02	01	H3305_021_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3305	021	0	1	02	01	H3305_021_0	10			Preferred Generic	4	01	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3305	021	0	1	02	01	H3305_021_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H3305	021	0	1	02	01	H3305_021_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	021	0	1	02	01	H3305_021_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				95.31	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	021	0	1	02	01	H3305_021_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1483.63	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3305	022	0	1	02	01	H3305_022_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3305	022	0	1	02	01	H3305_022_0	10			Preferred Generic	4	01	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3305	022	0	1	02	01	H3305_022_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		30.00				15.00		15.00
H3305	022	0	1	02	01	H3305_022_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	022	0	1	02	01	H3305_022_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				105.54	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	022	0	1	02	01	H3305_022_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1607.37	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3305	030	0	1	02	01	H3305_030_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3305	030	0	1	02	01	H3305_030_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		30.00				15.00		15.00
H3305	030	0	1	02	01	H3305_030_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	030	0	1	02	01	H3305_030_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				98.02	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	030	0	1	02	01	H3305_030_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1410.69	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3305	032	0	1	02	01	H3305_032_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3305	032	0	1	02	01	H3305_032_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H3305	032	0	1	02	01	H3305_032_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	032	0	1	02	01	H3305_032_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				105.63	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3305	032	0	1	02	01	H3305_032_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1523.37	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3307	002	0	1	02	01	H3307_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	002	0	1	02	01	H3307_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3307	002	0	1	02	01	H3307_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	002	0	1	02	01	H3307_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3307	002	0	1	02	01	H3307_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	002	0	1	02	01	H3307_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	002	0	1	02	01	H3307_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				307.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	012	0	1	02	01	H3307_012_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	012	0	1	02	01	H3307_012_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3307	012	0	1	02	01	H3307_012_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	012	0	1	02	01	H3307_012_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3307	012	0	1	02	01	H3307_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	012	0	1	02	01	H3307_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	012	0	1	02	01	H3307_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				257.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	015	0	1	02	01	H3307_015_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	015	0	1	02	01	H3307_015_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3307	015	0	1	02	01	H3307_015_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	015	0	1	02	01	H3307_015_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3307	015	0	1	02	01	H3307_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	015	0	1	02	01	H3307_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	015	0	1	02	01	H3307_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				219.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	023	0	1	02	01	H3307_023_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	023	0	1	02	01	H3307_023_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3307	023	0	1	02	01	H3307_023_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3307	023	0	1	02	01	H3307_023_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3307	023	0	1	02	01	H3307_023_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	023	0	1	02	01	H3307_023_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3307	023	0	1	02	01	H3307_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				227.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	002	0	1	01	01	H3312_002_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	002	0	1	01	01	H3312_002_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	002	0	1	01	01	H3312_002_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	002	0	1	01	01	H3312_002_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	002	0	1	01	01	H3312_002_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	002	0	1	01	01	H3312_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	002	0	1	01	01	H3312_002_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											764.67	28						533.51	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	018	0	1	01	01	H3312_018_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	018	0	1	01	01	H3312_018_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	018	0	1	01	01	H3312_018_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	018	0	1	01	01	H3312_018_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	018	0	1	01	01	H3312_018_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.79	25	25	25				48.37	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	018	0	1	01	01	H3312_018_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.28	50	50	50				64.90	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	018	0	1	01	01	H3312_018_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											944.52	33						682.19	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	048	0	1	01	01	H3312_048_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	048	0	1	01	01	H3312_048_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	048	0	1	01	01	H3312_048_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	048	0	1	01	01	H3312_048_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	048	0	1	01	01	H3312_048_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	048	0	1	01	01	H3312_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	048	0	1	01	01	H3312_048_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											814.93	33						577.89	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	062	0	1	02	01	H3312_062_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	062	0	1	02	01	H3312_062_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	062	0	1	02	01	H3312_062_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	062	0	1	02	01	H3312_062_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	062	0	1	02	01	H3312_062_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											52.74	25	25	25				47.50	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	062	0	1	02	01	H3312_062_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											99.29	50	50	50				67.26	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	062	0	1	02	01	H3312_062_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											847.25	33						699.53	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	064	0	1	01	01	H3312_064_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	064	0	1	01	01	H3312_064_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	064	0	1	01	01	H3312_064_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	064	0	1	01	01	H3312_064_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	064	0	1	01	01	H3312_064_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.15	25	25	25				71.92	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	064	0	1	01	01	H3312_064_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.56	40	40	40				80.09	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	064	0	1	01	01	H3312_064_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											763.75	29						563.55	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	065	0	1	02	01	H3312_065_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	065	0	1	02	01	H3312_065_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	065	0	1	02	01	H3312_065_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	065	0	1	02	01	H3312_065_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	065	0	1	02	01	H3312_065_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	065	0	1	02	01	H3312_065_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	065	0	1	02	01	H3312_065_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											751.04	30						598.73	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	072	0	1	01	01	H3312_072_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	072	0	1	01	01	H3312_072_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	072	0	1	01	01	H3312_072_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	072	0	1	01	01	H3312_072_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	072	0	1	01	01	H3312_072_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.50	25	25	25				75.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	072	0	1	01	01	H3312_072_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.74	40	40	40				82.43	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	072	0	1	01	01	H3312_072_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											789.14	29						582.09	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3312	074	0	1	01	01	H3312_074_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	074	0	1	01	01	H3312_074_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	074	0	1	01	01	H3312_074_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	074	0	1	01	01	H3312_074_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3312	074	0	1	01	01	H3312_074_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.80	25	25	25				48.49	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3312	074	0	1	01	01	H3312_074_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.82	50	50	50				66.84	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3312	074	0	1	01	01	H3312_074_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											905.68	33						658.69	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3330	021	1	1	01	01	H3330_021_1	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.07		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	1	1	01	01	H3330_021_1	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	1	1	01	01	H3330_021_1	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3330	021	1	1	01	01	H3330_021_1	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	1	1	01	01	H3330_021_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3330	021	1	1	01	01	H3330_021_1	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	1	1	01	01	H3330_021_1	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3330	021	2	1	01	01	H3330_021_2	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.07		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	2	1	01	01	H3330_021_2	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	2	1	01	01	H3330_021_2	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3330	021	2	1	01	01	H3330_021_2	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	2	1	01	01	H3330_021_2	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3330	021	2	1	01	01	H3330_021_2	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	2	1	01	01	H3330_021_2	9			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3330	021	3	1	01	01	H3330_021_3	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.07		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	3	1	01	01	H3330_021_3	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	3	1	01	01	H3330_021_3	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3330	021	3	1	01	01	H3330_021_3	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	3	1	01	01	H3330_021_3	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3330	021	3	1	01	01	H3330_021_3	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	021	3	1	01	01	H3330_021_3	9			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3330	038	0	1	01	01	H3330_038_0	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.07		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	038	0	1	01	01	H3330_038_0	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	038	0	1	01	01	H3330_038_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3330	038	0	1	01	01	H3330_038_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	038	0	1	01	01	H3330_038_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3330	038	0	1	01	01	H3330_038_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	038	0	1	01	01	H3330_038_0	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3330	045	0	1	01	01	H3330_045_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.07		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	045	0	1	01	01	H3330_045_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.50		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	045	0	1	01	01	H3330_045_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3330	045	0	1	01	01	H3330_045_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	045	0	1	01	01	H3330_045_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3330	045	0	1	01	01	H3330_045_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3330	045	0	1	01	01	H3330_045_0	9			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3335	015	0	1	04	01	H3335_015_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	015	0	1	04	01	H3335_015_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	22.00					6.00	12.00	12.00											11.00	22.00	22.00				6.00	12.00	12.00				11.00				6.00			0.37	0.20		0.37	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	22.00	6.00	12.00	12.00	11.00	22.00	22.00	6.00	12.00	12.00	11.00		6.00
H3335	015	0	1	04	01	H3335_015_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	015	0	1	04	01	H3335_015_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	015	0	1	04	01	H3335_015_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	33	33	33				1.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	018	0	1	04	01	H3335_018_0	5			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								19.00	38.00	57.00					14.00	28.00	42.00											19.00	38.00	57.00				14.00	28.00	42.00				19.00				14.00			0.63	0.47		0.63	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00	38.00	57.00	14.00	28.00	42.00	19.00	38.00	57.00	14.00	28.00	42.00	19.00		14.00
H3335	018	0	1	04	01	H3335_018_0	5			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00
H3335	018	0	1	04	01	H3335_018_0	5			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3335	018	0	1	04	01	H3335_018_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											96.00	27	27	27				93.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3335	018	0	1	04	01	H3335_018_0	5			Specialty Tier	3	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	25	25	25				1.00	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3335	038	0	1	04	01	H3335_038_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	038	0	1	04	01	H3335_038_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	26.00					8.00	16.00	16.00											13.00	26.00	26.00				8.00	16.00	16.00				13.00				8.00			0.43	0.27		0.43	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	26.00	8.00	16.00	16.00	13.00	26.00	26.00	8.00	16.00	16.00	13.00		8.00
H3335	038	0	1	04	01	H3335_038_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	038	0	1	04	01	H3335_038_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	038	0	1	04	01	H3335_038_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	33	33	33				1.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	053	0	1	04	01	H3335_053_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	053	0	1	04	01	H3335_053_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	30.00					10.00	20.00	20.00											15.00	30.00	30.00				10.00	20.00	20.00				15.00				10.00			0.50	0.33		0.50	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	30.00	10.00	20.00	20.00	15.00	30.00	30.00	10.00	20.00	20.00	15.00		10.00
H3335	053	0	1	04	01	H3335_053_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	053	0	1	04	01	H3335_053_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	053	0	1	04	01	H3335_053_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	30	30	30				1.00	30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	055	0	1	04	01	H3335_055_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	055	0	1	04	01	H3335_055_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	34.00					12.00	24.00	24.00											17.00	34.00	34.00				12.00	24.00	24.00				17.00				12.00			0.57	0.40		0.57	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	34.00	12.00	24.00	24.00	17.00	34.00	34.00	12.00	24.00	24.00	17.00		12.00
H3335	055	0	1	04	01	H3335_055_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	055	0	1	04	01	H3335_055_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											97.00	23	23	23				98.00	23	23	23										23	23	23				23	23	23			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	055	0	1	04	01	H3335_055_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	27	27	27				1.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3335	056	0	1	04	01	H3335_056_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	056	0	1	04	01	H3335_056_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	34.00					12.00	24.00	24.00											17.00	34.00	34.00				12.00	24.00	24.00				17.00				12.00			0.57	0.40		0.57	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	34.00	12.00	24.00	24.00	17.00	34.00	34.00	12.00	24.00	24.00	17.00		12.00
H3335	056	0	1	04	01	H3335_056_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	056	0	1	04	01	H3335_056_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	056	0	1	04	01	H3335_056_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	27	27	27				1.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	057	0	1	04	01	H3335_057_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	057	0	1	04	01	H3335_057_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	34.00					12.00	24.00	24.00											17.00	34.00	34.00				12.00	24.00	24.00				17.00				12.00			0.57	0.40		0.57	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	34.00	12.00	24.00	24.00	17.00	34.00	34.00	12.00	24.00	24.00	17.00		12.00
H3335	057	0	1	04	01	H3335_057_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	057	0	1	04	01	H3335_057_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	057	0	1	04	01	H3335_057_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	27	27	27				1.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	058	0	1	04	01	H3335_058_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3335	058	0	1	04	01	H3335_058_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	34.00					12.00	24.00	24.00											17.00	34.00	34.00				12.00	24.00	24.00				17.00				12.00			0.57	0.40		0.57	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	34.00	12.00	24.00	24.00	17.00	34.00	34.00	12.00	24.00	24.00	17.00		12.00
H3335	058	0	1	04	01	H3335_058_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	058	0	1	04	01	H3335_058_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3335	058	0	1	04	01	H3335_058_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	29	29	29				1.00	29	29	29										29	29	29				29	29	29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3342	023	1	1	04	01	H3342_023_1	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					3.00	9.00	9.00																8.00				8.00			0.27	0.10	0.10			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	1	1	04	01	H3342_023_1	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					10.00	30.00	30.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	1	1	04	01	H3342_023_1	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								43.00	86.00	129.00					38.00	76.00	114.00					38.00	114.00	114.00																43.00				43.00			1.43	1.27	1.27			1.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3342	023	1	1	04	01	H3342_023_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								93.00	186.00	279.00					88.00	176.00	264.00					88.00	264.00	264.00																93.00				93.00			3.10	2.93	2.93			2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	1	1	04	01	H3342_023_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	1	1	04	01	H3342_023_1	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	1	1	04	01	H3342_023_1	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3342	023	2	1	04	01	H3342_023_2	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					3.00	9.00	9.00																8.00				8.00			0.27	0.10	0.10			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	2	1	04	01	H3342_023_2	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					10.00	30.00	30.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	2	1	04	01	H3342_023_2	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								43.00	86.00	129.00					38.00	76.00	114.00					38.00	114.00	114.00																43.00				43.00			1.43	1.27	1.27			1.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3342	023	2	1	04	01	H3342_023_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								93.00	186.00	279.00					88.00	176.00	264.00					88.00	264.00	264.00																93.00				93.00			3.10	2.93	2.93			2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	2	1	04	01	H3342_023_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	2	1	04	01	H3342_023_2	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3342	023	2	1	04	01	H3342_023_2	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3344	005	0	1	04	01	H3344_005_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3344	005	0	1	04	01	H3344_005_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	15.00		37.50																					37.50																15.00				15.00		0.50						0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		37.50						37.50				15.00		15.00
H3344	005	0	1	04	01	H3344_005_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	47.00		117.50																					117.50																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3344	005	0	1	04	01	H3344_005_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				98.56	43		43																				43															43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3344	005	0	1	04	01	H3344_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				775.54	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3344	010	0	1	04	01	H3344_010_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3344	010	0	1	04	01	H3344_010_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	10.00		25.00																					25.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		25.00						25.00				10.00		10.00
H3344	010	0	1	04	01	H3344_010_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	45.00		112.50																					112.50																45.00				45.00		1.50						1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3344	010	0	1	04	01	H3344_010_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				94.52	50		50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3344	010	0	1	04	01	H3344_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				938.77	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3344	012	0	1	04	01	H3344_012_0	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3344	012	0	1	04	01	H3344_012_0	8			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	17.00		42.50																					42.50																17.00				17.00		0.57						0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		42.50						42.50				17.00		17.00
H3344	012	0	1	04	01	H3344_012_0	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	47.00		117.50																					117.50																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3344	012	0	1	04	01	H3344_012_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				99.85	48		48																				48															48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3344	012	0	1	04	01	H3344_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				707.40	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3347	009	0	1	02	01	H3347_009_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	4.00	8.00	12.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00						8.00				4.00		4.00
H3347	009	0	1	02	01	H3347_009_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00						20.00				10.00		10.00
H3347	009	0	1	02	01	H3347_009_0	10			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	009	0	1	02	01	H3347_009_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	009	0	1	02	01	H3347_009_0	10			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				966.27	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	015	0	1	02	01	H3347_015_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	4.00	8.00	12.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00						8.00				4.00		4.00
H3347	015	0	1	02	01	H3347_015_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	14.00	28.00	42.00																					28.00																14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00						28.00				14.00		14.00
H3347	015	0	1	02	01	H3347_015_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	015	0	1	02	01	H3347_015_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				1	2			90				30		31				55.43	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	015	0	1	02	01	H3347_015_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				913.19	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	016	0	1	02	01	H3347_016_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H3347	016	0	1	02	01	H3347_016_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00						20.00				10.00		10.00
H3347	016	0	1	02	01	H3347_016_0	10			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	016	0	1	02	01	H3347_016_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	016	0	1	02	01	H3347_016_0	10			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				857.49	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	018	0	1	02	01	H3347_018_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	4.00	8.00	12.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00						8.00				4.00		4.00
H3347	018	0	1	02	01	H3347_018_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	14.00	28.00	42.00																					28.00																14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00						28.00				14.00		14.00
H3347	018	0	1	02	01	H3347_018_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	018	0	1	02	01	H3347_018_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				1	2			90				30		31				84.77	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3347	018	0	1	02	01	H3347_018_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				837.49	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						70.00				35.00		35.00
H3351	002	0	1	02	01	H3351_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	002	0	1	02	01	H3351_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				5.00	10.00	10.00				10.00				5.00			0.33	0.17		0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	5.00	10.00	10.00	10.00	20.00	20.00	5.00	10.00	10.00	10.00		5.00
H3351	002	0	1	02	01	H3351_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	002	0	1	02	01	H3351_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	002	0	1	02	01	H3351_002_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	33	33	33				1.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	006	0	1	02	01	H3351_006_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	006	0	1	02	01	H3351_006_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	34.00					12.00	24.00	24.00											17.00	34.00	34.00				12.00	24.00	24.00				17.00				12.00			0.57	0.40		0.57	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	34.00	12.00	24.00	24.00	17.00	34.00	34.00	12.00	24.00	24.00	17.00		12.00
H3351	006	0	1	02	01	H3351_006_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	006	0	1	02	01	H3351_006_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	006	0	1	02	01	H3351_006_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	33	33	33				1.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	012	0	1	02	01	H3351_012_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	012	0	1	02	01	H3351_012_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	30.00					10.00	20.00	20.00											15.00	30.00	30.00				10.00	20.00	20.00				15.00				10.00			0.50	0.33		0.50	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	30.00	10.00	20.00	20.00	15.00	30.00	30.00	10.00	20.00	20.00	15.00		10.00
H3351	012	0	1	02	01	H3351_012_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	012	0	1	02	01	H3351_012_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	012	0	1	02	01	H3351_012_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	33	33	33				1.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	013	0	1	02	01	H3351_013_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	013	0	1	02	01	H3351_013_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	40.00					15.00	30.00	30.00											20.00	40.00	40.00				15.00	30.00	30.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	15.00	30.00	30.00	20.00	40.00	40.00	15.00	30.00	30.00	20.00		15.00
H3351	013	0	1	02	01	H3351_013_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	013	0	1	02	01	H3351_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	013	0	1	02	01	H3351_013_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	33	33	33				1.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	016	0	1	01	01	H3351_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	016	0	1	01	01	H3351_016_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	40.00					15.00	30.00	30.00											20.00	40.00	40.00				15.00	30.00	30.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	15.00	30.00	30.00	20.00	40.00	40.00	15.00	30.00	30.00	20.00		15.00
H3351	016	0	1	01	01	H3351_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	016	0	1	01	01	H3351_016_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	016	0	1	01	01	H3351_016_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	27	27	27				1.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	017	0	1	01	01	H3351_017_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	017	0	1	01	01	H3351_017_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								19.00	38.00	38.00					14.00	28.00	28.00											19.00	38.00	38.00				14.00	28.00	28.00				19.00				14.00			0.63	0.47		0.63	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00	38.00	38.00	14.00	28.00	28.00	19.00	38.00	38.00	14.00	28.00	28.00	19.00		14.00
H3351	017	0	1	01	01	H3351_017_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	017	0	1	01	01	H3351_017_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	017	0	1	01	01	H3351_017_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	30	30	30				1.00	30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	018	0	1	02	01	H3351_018_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	018	0	1	02	01	H3351_018_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	40.00					15.00	30.00	30.00											20.00	40.00	40.00				15.00	30.00	30.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	15.00	30.00	30.00	20.00	40.00	40.00	15.00	30.00	30.00	20.00		15.00
H3351	018	0	1	02	01	H3351_018_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	018	0	1	02	01	H3351_018_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	018	0	1	02	01	H3351_018_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	28	28	28				1.00	28	28	28										28	28	28				28	28	28			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00	60.00	60.00	25.00	50.00	50.00	30.00	60.00	60.00	25.00	50.00	50.00	30.00		25.00
H3351	019	0	1	02	01	H3351_019_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	019	0	1	02	01	H3351_019_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								19.00	38.00	38.00					14.00	28.00	28.00											19.00	38.00	38.00				14.00	28.00	28.00				19.00				14.00			0.63	0.47		0.63	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00	38.00	38.00	14.00	28.00	28.00	19.00	38.00	38.00	14.00	28.00	28.00	19.00		14.00
H3351	019	0	1	02	01	H3351_019_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	019	0	1	02	01	H3351_019_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	200.00					95.00	190.00	190.00											100.00	200.00	200.00				95.00	190.00	190.00				100.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	019	0	1	02	01	H3351_019_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	31	31	31				1.00	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	020	0	1	01	01	H3351_020_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	020	0	1	01	01	H3351_020_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	34.00					12.00	24.00	24.00											17.00	34.00	34.00				12.00	24.00	24.00				17.00				12.00			0.57	0.40		0.57	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	34.00	12.00	24.00	24.00	17.00	34.00	34.00	12.00	24.00	24.00	17.00		12.00
H3351	020	0	1	01	01	H3351_020_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	020	0	1	01	01	H3351_020_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.00	21	21	21				88.00	21	21	21										21	21	21				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	020	0	1	01	01	H3351_020_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	27	27	27				1.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	021	0	1	01	01	H3351_021_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		0.00
H3351	021	0	1	01	01	H3351_021_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	40.00					15.00	30.00	30.00											20.00	40.00	40.00				15.00	30.00	30.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	15.00	30.00	30.00	20.00	40.00	40.00	15.00	30.00	30.00	20.00		15.00
H3351	021	0	1	01	01	H3351_021_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	94.00					42.00	84.00	84.00											47.00	94.00	94.00				42.00	84.00	84.00				47.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	021	0	1	01	01	H3351_021_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											95.00	21	21	21				82.00	21	21	21										21	21	21				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3351	021	0	1	01	01	H3351_021_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	27	27	27				1.00	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00
H3359	001	0	1	01	01	H3359_001_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3359	001	0	1	01	01	H3359_001_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	10.00																			10.00	20.00	10.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													10.00	20.00	10.00				10.00	20.00	10.00				10.00		10.00
H3359	001	0	1	01	01	H3359_001_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	35.00	70.00	35.00																			35.00	70.00	35.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H3359	001	0	1	01	01	H3359_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H3359	001	0	1	01	01	H3359_001_0	12			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H3359	001	0	1	01	01	H3359_001_0	12			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H3359	001	0	1	01	01	H3359_001_0	12			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H3359	019	0	1	01	01	H3359_019_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3359	019	0	1	01	01	H3359_019_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H3359	019	0	1	01	01	H3359_019_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	019	0	1	01	01	H3359_019_0	12			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.04	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	019	0	1	01	01	H3359_019_0	12			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	019	0	1	01	01	H3359_019_0	12			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H3359	019	0	1	01	01	H3359_019_0	12			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H3359	021	0	1	01	01	H3359_021_0	17		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H3359	021	0	1	01	01	H3359_021_0	17		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H3359	021	0	1	01	01	H3359_021_0	17		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				22.47	16	16	16																		16	16	16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	021	0	1	01	01	H3359_021_0	17		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.02	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	021	0	1	01	01	H3359_021_0	17		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	021	0	1	01	01	H3359_021_0	17		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H3359	021	0	1	01	01	H3359_021_0	17		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H3359	034	0	1	01	01	H3359_034_0	11		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3359	034	0	1	01	01	H3359_034_0	11		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H3359	034	0	1	01	01	H3359_034_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				23.89	19	19	19																		19	19	19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	034	0	1	01	01	H3359_034_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.61	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	034	0	1	01	01	H3359_034_0	11		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	038	0	1	01	01	H3359_038_0	12		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3359	038	0	1	01	01	H3359_038_0	12		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H3359	038	0	1	01	01	H3359_038_0	12		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	038	0	1	01	01	H3359_038_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				59.79	44	44	44																		44	44	44															44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3359	038	0	1	01	01	H3359_038_0	12		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3362	017	0	1	01	01	H3362_017_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3362	017	0	1	01	01	H3362_017_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	10.00		25.00																					25.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		25.00						25.00				10.00		10.00
H3362	017	0	1	01	01	H3362_017_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	42.00		105.00																					105.00																42.00				42.00		1.40						1.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	017	0	1	01	01	H3362_017_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				98.46	49		49																				49															49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	017	0	1	01	01	H3362_017_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				808.84	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3362	020	0	1	01	01	H3362_020_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	4.00		10.00																					10.00																4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		10.00						10.00				4.00		4.00
H3362	020	0	1	01	01	H3362_020_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	15.00		37.50																					37.50																15.00				15.00		0.50						0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		37.50						37.50				15.00		15.00
H3362	020	0	1	01	01	H3362_020_0	7			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				2	2			90				30		34				73.05	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	020	0	1	01	01	H3362_020_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				38.20	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	020	0	1	01	01	H3362_020_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				405.55	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3362	033	0	1	01	01	H3362_033_0	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3362	033	0	1	01	01	H3362_033_0	8			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	12.00		30.00																					30.00																12.00				12.00		0.40						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		30.00						30.00				12.00		12.00
H3362	033	0	1	01	01	H3362_033_0	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	42.00		105.00																					105.00																42.00				42.00		1.40						1.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	033	0	1	01	01	H3362_033_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				95.77	50		50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	033	0	1	01	01	H3362_033_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				718.23	32																																					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3362	038	0	1	01	01	H3362_038_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3362	038	0	1	01	01	H3362_038_0	9			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	15.00		37.50																					37.50																15.00				15.00		0.50						0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		37.50						37.50				15.00		15.00
H3362	038	0	1	01	01	H3362_038_0	9			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	47.00		117.50																					117.50																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	038	0	1	01	01	H3362_038_0	9			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				98.97	49		49																				49															49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	038	0	1	01	01	H3362_038_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				729.36	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3362	039	0	1	01	01	H3362_039_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	3.00		7.50																					7.50																3.00				3.00		0.10						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		7.50						7.50				3.00		3.00
H3362	039	0	1	01	01	H3362_039_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	20.00		50.00																					50.00																20.00				20.00		0.67						0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		50.00						50.00				20.00		20.00
H3362	039	0	1	01	01	H3362_039_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	47.00		117.50																					117.50																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	039	0	1	01	01	H3362_039_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				98.52	41		41																				41															41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	039	0	1	01	01	H3362_039_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				679.76	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3362	040	0	1	01	01	H3362_040_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H3362	040	0	1	01	01	H3362_040_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	12.00		30.00																					30.00																12.00				12.00		0.40						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		30.00						30.00				12.00		12.00
H3362	040	0	1	01	01	H3362_040_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	47.00		117.50																					117.50																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	040	0	1	01	01	H3362_040_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				77.94	38		38																				38															38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		87.50						87.50				35.00		35.00
H3362	040	0	1	01	01	H3362_040_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				689.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	001	0	1	02	01	H3379_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	001	0	1	02	01	H3379_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	001	0	1	02	01	H3379_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	001	0	1	02	01	H3379_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	001	0	1	02	01	H3379_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	001	0	1	02	01	H3379_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	001	0	1	02	01	H3379_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				273.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	039	0	1	02	01	H3379_039_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	039	0	1	02	01	H3379_039_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	039	0	1	02	01	H3379_039_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	039	0	1	02	01	H3379_039_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	039	0	1	02	01	H3379_039_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	039	0	1	02	01	H3379_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	039	0	1	02	01	H3379_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				446.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	040	0	1	02	01	H3379_040_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	040	0	1	02	01	H3379_040_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	040	0	1	02	01	H3379_040_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	040	0	1	02	01	H3379_040_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	040	0	1	02	01	H3379_040_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	040	0	1	02	01	H3379_040_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	040	0	1	02	01	H3379_040_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				532.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	041	0	1	02	01	H3379_041_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	041	0	1	02	01	H3379_041_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	041	0	1	02	01	H3379_041_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	041	0	1	02	01	H3379_041_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	041	0	1	02	01	H3379_041_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	041	0	1	02	01	H3379_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	041	0	1	02	01	H3379_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				203.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	043	0	1	02	01	H3379_043_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	043	0	1	02	01	H3379_043_0	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	043	0	1	02	01	H3379_043_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	043	0	1	02	01	H3379_043_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	043	0	1	02	01	H3379_043_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	42.00		126.00																											126.00						116.00				42.00				42.00		1.40						1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	043	0	1	02	01	H3379_043_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	94.00		282.00																											282.00						272.00				94.00				94.00		3.13						3.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	043	0	1	02	01	H3379_043_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				299.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	045	0	1	02	01	H3379_045_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	045	0	1	02	01	H3379_045_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	045	0	1	02	01	H3379_045_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	045	0	1	02	01	H3379_045_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	045	0	1	02	01	H3379_045_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	045	0	1	02	01	H3379_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	045	0	1	02	01	H3379_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				435.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	046	0	1	02	01	H3379_046_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	046	0	1	02	01	H3379_046_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	046	0	1	02	01	H3379_046_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	046	0	1	02	01	H3379_046_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	046	0	1	02	01	H3379_046_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	046	0	1	02	01	H3379_046_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	046	0	1	02	01	H3379_046_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	050	0	1	02	01	H3379_050_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	050	0	1	02	01	H3379_050_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	050	0	1	02	01	H3379_050_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	050	0	1	02	01	H3379_050_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	050	0	1	02	01	H3379_050_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	050	0	1	02	01	H3379_050_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	050	0	1	02	01	H3379_050_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				446.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	051	0	1	02	01	H3379_051_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	051	0	1	02	01	H3379_051_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3379	051	0	1	02	01	H3379_051_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3379	051	0	1	02	01	H3379_051_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3379	051	0	1	02	01	H3379_051_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	051	0	1	02	01	H3379_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3379	051	0	1	02	01	H3379_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				315.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	013	0	1	01	01	H3384_013_0	9			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					2.00		6.00											7.00		17.50				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	013	0	1	01	01	H3384_013_0	9			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								15.00		45.00					10.00		30.00											15.00		37.50				10.00		25.00				15.00				15.00			0.48	0.32		0.48	0.32	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	013	0	1	01	01	H3384_013_0	9			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H3384	013	0	1	01	01	H3384_013_0	9			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	013	0	1	01	01	H3384_013_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1115.93	33						1115.93	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	019	0	1	01	01	H3384_019_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					2.00		6.00											7.00		17.50				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	019	0	1	01	01	H3384_019_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								15.00		45.00					10.00		30.00											15.00		37.50				10.00		25.00				15.00				15.00			0.48	0.32		0.48	0.32	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	019	0	1	01	01	H3384_019_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H3384	019	0	1	01	01	H3384_019_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	019	0	1	01	01	H3384_019_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											942.28	33						942.28	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	058	0	1	01	01	H3384_058_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					2.00		6.00											7.00		17.50				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	058	0	1	01	01	H3384_058_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								15.00		45.00					10.00		30.00											15.00		37.50				10.00		25.00				15.00				15.00			0.48	0.32		0.48	0.32	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	058	0	1	01	01	H3384_058_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H3384	058	0	1	01	01	H3384_058_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	058	0	1	01	01	H3384_058_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1065.87	30						1065.87	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	059	0	1	01	01	H3384_059_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					2.00		6.00											7.00		17.50				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	059	0	1	01	01	H3384_059_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								13.00		39.00					8.00		24.00											13.00		32.50				8.00		20.00				13.00				13.00			0.42	0.26		0.42	0.26	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	059	0	1	01	01	H3384_059_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H3384	059	0	1	01	01	H3384_059_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	059	0	1	01	01	H3384_059_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											801.03	28						801.03	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	062	0	1	01	01	H3384_062_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								5.00		15.00					0.00		0.00											5.00		12.50				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	062	0	1	01	01	H3384_062_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								17.00		51.00					12.00		36.00											17.00		42.50				12.00		0.00				17.00				17.00			0.55	0.39		0.55	0.39	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	062	0	1	01	01	H3384_062_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H3384	062	0	1	01	01	H3384_062_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	062	0	1	01	01	H3384_062_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											949.17	29						949.17	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	063	0	1	01	01	H3384_063_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								8.00		24.00					3.00		9.00											8.00		20.00				3.00		0.00				8.00				8.00			0.26	0.10		0.26	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	063	0	1	01	01	H3384_063_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								15.00		45.00					10.00		30.00											15.00		37.50				10.00		25.00				15.00				15.00			0.48	0.32		0.48	0.32	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	063	0	1	01	01	H3384_063_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H3384	063	0	1	01	01	H3384_063_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	063	0	1	01	01	H3384_063_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											760.30	28						760.30	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	067	0	1	01	01	H3384_067_0	7			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								9.00		27.00					0.00		0.00											9.00		22.50				0.00		0.00				9.00				9.00			0.29	0.00		0.29	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	067	0	1	01	01	H3384_067_0	7			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								17.00		51.00					12.00		36.00											17.00		42.50				12.00		30.00				17.00				17.00			0.55	0.39		0.55	0.39	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	067	0	1	01	01	H3384_067_0	7			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H3384	067	0	1	01	01	H3384_067_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3384	067	0	1	01	01	H3384_067_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1102.03	27						1102.03	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	002	0	1	01	01	H3388_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	002	0	1	01	01	H3388_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	48.00					0.00	0.00	0.00											16.00	32.00	48.00				0.00	0.00	0.00				16.00				16.00			0.53	0.00		0.53	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	002	0	1	01	01	H3388_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								45.00	90.00	135.00					40.00	80.00	120.00											45.00	90.00	135.00				40.00	80.00	80.00				45.00				45.00			1.50	1.33		1.50	1.33	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3388	002	0	1	01	01	H3388_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								90.00	180.00	270.00					90.00	180.00	270.00											90.00	180.00	270.00				90.00	180.00	225.00				90.00				90.00			3.00	3.00		3.00	3.00	2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	002	0	1	01	01	H3388_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1588.16	33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	004	0	1	01	01	H3388_004_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	004	0	1	01	01	H3388_004_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					0.00	0.00	0.00											18.00	36.00	54.00				0.00	0.00	0.00				18.00				18.00			0.60	0.00		0.60	0.00	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	004	0	1	01	01	H3388_004_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3388	004	0	1	01	01	H3388_004_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								93.00	186.00	279.00					93.00	186.00	279.00											93.00	186.00	279.00				93.00	186.00	232.50				93.00				93.00			3.10	3.10		3.10	3.10	3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	004	0	1	01	01	H3388_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1662.83	33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	013	0	1	01	01	H3388_013_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	013	0	1	01	01	H3388_013_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	013	0	1	01	01	H3388_013_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3388	013	0	1	01	01	H3388_013_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								97.00	194.00	291.00					97.00	194.00	291.00											97.00	194.00	291.00				97.00	194.00	242.50				97.00				97.00			3.23	3.23		3.23	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	013	0	1	01	01	H3388_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1919.14	33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	014	0	1	01	01	H3388_014_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	014	0	1	01	01	H3388_014_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	014	0	1	01	01	H3388_014_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3388	014	0	1	01	01	H3388_014_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	250.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	014	0	1	01	01	H3388_014_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1399.46	27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	018	0	1	01	01	H3388_018_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	018	0	1	01	01	H3388_018_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	018	0	1	01	01	H3388_018_0	7			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3388	018	0	1	01	01	H3388_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	250.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3388	018	0	1	01	01	H3388_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3404	003	1	1	04	01	H3404_003_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3404	003	1	1	04	01	H3404_003_1	6			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3404	003	1	1	04	01	H3404_003_1	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3404	003	1	1	04	01	H3404_003_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3404	003	1	1	04	01	H3404_003_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											996.34	33						943.29	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3404	003	1	1	04	01	H3404_003_1	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3404	003	1	1	04	01	H3404_003_1	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3404	003	2	1	04	01	H3404_003_2	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3404	003	2	1	04	01	H3404_003_2	7			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3404	003	2	1	04	01	H3404_003_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3404	003	2	1	04	01	H3404_003_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3404	003	2	1	04	01	H3404_003_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											996.34	33						943.29	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3404	003	2	1	04	01	H3404_003_2	7			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3404	003	2	1	04	01	H3404_003_2	7			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3416	001	6	1	04	01	H3416_001_6	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	001	6	1	04	01	H3416_001_6	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H3416	001	6	1	04	01	H3416_001_6	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		117.50				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	001	6	1	04	01	H3416_001_6	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				1	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		250.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	001	6	1	04	01	H3416_001_6	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				999.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	001	7	1	04	01	H3416_001_7	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	001	7	1	04	01	H3416_001_7	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H3416	001	7	1	04	01	H3416_001_7	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		117.50				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	001	7	1	04	01	H3416_001_7	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				1	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		250.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	001	7	1	04	01	H3416_001_7	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				999.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	002	4	1	04	01	H3416_002_4	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	002	4	1	04	01	H3416_002_4	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3416	002	4	1	04	01	H3416_002_4	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H3416	002	4	1	04	01	H3416_002_4	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3416	002	4	1	04	01	H3416_002_4	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		117.50				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	002	4	1	04	01	H3416_002_4	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				1	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		250.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	002	4	1	04	01	H3416_002_4	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				999.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	002	5	1	04	01	H3416_002_5	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3416	002	5	1	04	01	H3416_002_5	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3416	002	5	1	04	01	H3416_002_5	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H3416	002	5	1	04	01	H3416_002_5	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3416	002	5	1	04	01	H3416_002_5	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		117.50				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	002	5	1	04	01	H3416_002_5	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				1	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		250.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		87.50	35.00		35.00
H3416	002	5	1	04	01	H3416_002_5	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				999.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	001	0	1	04	01	H3418_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	001	0	1	04	01	H3418_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	001	0	1	04	01	H3418_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	001	0	1	04	01	H3418_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	001	0	1	04	01	H3418_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	001	0	1	04	01	H3418_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	001	0	1	04	01	H3418_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				351.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	002	0	1	04	01	H3418_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	002	0	1	04	01	H3418_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	002	0	1	04	01	H3418_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	002	0	1	04	01	H3418_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	002	0	1	04	01	H3418_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	002	0	1	04	01	H3418_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	002	0	1	04	01	H3418_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				347.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	003	0	1	04	01	H3418_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	003	0	1	04	01	H3418_003_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	003	0	1	04	01	H3418_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	003	0	1	04	01	H3418_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	003	0	1	04	01	H3418_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	003	0	1	04	01	H3418_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	003	0	1	04	01	H3418_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				255.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	004	0	1	04	01	H3418_004_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	004	0	1	04	01	H3418_004_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	004	0	1	04	01	H3418_004_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	004	0	1	04	01	H3418_004_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	004	0	1	04	01	H3418_004_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	004	0	1	04	01	H3418_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	004	0	1	04	01	H3418_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				303.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	005	0	1	04	01	H3418_005_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	005	0	1	04	01	H3418_005_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	005	0	1	04	01	H3418_005_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	005	0	1	04	01	H3418_005_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	005	0	1	04	01	H3418_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	005	0	1	04	01	H3418_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	005	0	1	04	01	H3418_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				232.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	006	0	1	04	01	H3418_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	006	0	1	04	01	H3418_006_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	006	0	1	04	01	H3418_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	006	0	1	04	01	H3418_006_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	006	0	1	04	01	H3418_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	006	0	1	04	01	H3418_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	006	0	1	04	01	H3418_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				231.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	007	0	1	04	01	H3418_007_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	007	0	1	04	01	H3418_007_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	007	0	1	04	01	H3418_007_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	007	0	1	04	01	H3418_007_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	007	0	1	04	01	H3418_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	007	0	1	04	01	H3418_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	007	0	1	04	01	H3418_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				437.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	008	0	1	04	01	H3418_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	008	0	1	04	01	H3418_008_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	008	0	1	04	01	H3418_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	008	0	1	04	01	H3418_008_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	008	0	1	04	01	H3418_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	008	0	1	04	01	H3418_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	008	0	1	04	01	H3418_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				270.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	009	0	1	04	01	H3418_009_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	009	0	1	04	01	H3418_009_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	009	0	1	04	01	H3418_009_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	009	0	1	04	01	H3418_009_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	009	0	1	04	01	H3418_009_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	009	0	1	04	01	H3418_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	009	0	1	04	01	H3418_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				169.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	010	0	1	04	01	H3418_010_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	010	0	1	04	01	H3418_010_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3418	010	0	1	04	01	H3418_010_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3418	010	0	1	04	01	H3418_010_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3418	010	0	1	04	01	H3418_010_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	010	0	1	04	01	H3418_010_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3418	010	0	1	04	01	H3418_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				235.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3419	003	0	1	01	01	H3419_003_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	003	0	1	01	01	H3419_003_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	003	0	1	01	01	H3419_003_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3419	003	0	1	01	01	H3419_003_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	003	0	1	01	01	H3419_003_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	004	0	1	01	01	H3419_004_0	11			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	004	0	1	01	01	H3419_004_0	11			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	004	0	1	01	01	H3419_004_0	11			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3419	004	0	1	01	01	H3419_004_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3419	004	0	1	01	01	H3419_004_0	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H3443	001	0	1	01	01	H3443_001_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	001	0	1	01	01	H3443_001_0	16			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	001	0	1	01	01	H3443_001_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	001	0	1	01	01	H3443_001_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	001	0	1	01	01	H3443_001_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	001	0	1	01	01	H3443_001_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				862.16	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	001	0	1	01	01	H3443_001_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	001	0	1	01	01	H3443_001_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	002	0	1	01	01	H3443_002_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	002	0	1	01	01	H3443_002_0	16			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	002	0	1	01	01	H3443_002_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	002	0	1	01	01	H3443_002_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	002	0	1	01	01	H3443_002_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	002	0	1	01	01	H3443_002_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				865.81	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	002	0	1	01	01	H3443_002_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	002	0	1	01	01	H3443_002_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	003	0	1	01	01	H3443_003_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	003	0	1	01	01	H3443_003_0	14			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	003	0	1	01	01	H3443_003_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	003	0	1	01	01	H3443_003_0	14			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	003	0	1	01	01	H3443_003_0	14			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	003	0	1	01	01	H3443_003_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				790.07	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	003	0	1	01	01	H3443_003_0	14			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	003	0	1	01	01	H3443_003_0	14			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	005	0	1	01	01	H3443_005_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	005	0	1	01	01	H3443_005_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3443	005	0	1	01	01	H3443_005_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3443	005	0	1	01	01	H3443_005_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	005	0	1	01	01	H3443_005_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3443	005	0	1	01	01	H3443_005_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				511.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	005	0	1	01	01	H3443_005_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3443	005	0	1	01	01	H3443_005_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	001	0	1	01	01	H3447_001_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	001	0	1	01	01	H3447_001_0	8			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H3447	001	0	1	01	01	H3447_001_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	001	0	1	01	01	H3447_001_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	001	0	1	01	01	H3447_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	001	0	1	01	01	H3447_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	001	0	1	01	01	H3447_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	001	0	1	01	01	H3447_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H3447	001	0	1	01	01	H3447_001_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	003	0	1	01	01	H3447_003_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	003	0	1	01	01	H3447_003_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H3447	003	0	1	01	01	H3447_003_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	003	0	1	01	01	H3447_003_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	003	0	1	01	01	H3447_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	003	0	1	01	01	H3447_003_0	7			Preferred Brand	4	11	1	2	3	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	1																
H3447	003	0	1	01	01	H3447_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	003	0	1	01	01	H3447_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	003	0	1	01	01	H3447_003_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H3447	003	0	1	01	01	H3447_003_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	004	0	1	01	01	H3447_004_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	004	0	1	01	01	H3447_004_0	6			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H3447	004	0	1	01	01	H3447_004_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	004	0	1	01	01	H3447_004_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	004	0	1	01	01	H3447_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	004	0	1	01	01	H3447_004_0	6			Preferred Brand	4	11	1	2	3	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	1																
H3447	004	0	1	01	01	H3447_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	004	0	1	01	01	H3447_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	004	0	1	01	01	H3447_004_0	6			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H3447	004	0	1	01	01	H3447_004_0	6			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	005	0	1	01	01	H3447_005_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	005	0	1	01	01	H3447_005_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								17.50	35.00	52.50					12.50	25.00	37.50					0.00	0.00	0.00																17.50				17.50			0.58	0.42	0.00			0.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	005	0	1	01	01	H3447_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	005	0	1	01	01	H3447_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					90.00	180.00	270.00					90.00	180.00	180.00																95.00				95.00			3.17	3.00	3.00			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	005	0	1	01	01	H3447_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	005	0	1	01	01	H3447_005_0	6			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H3447	005	0	1	01	01	H3447_005_0	6			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	010	0	1	01	01	H3447_010_0	6			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	010	0	1	01	01	H3447_010_0	6			Preferred Generic	4	01	3	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H3447	010	0	1	01	01	H3447_010_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	010	0	1	01	01	H3447_010_0	6			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	010	0	1	01	01	H3447_010_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3447	010	0	1	01	01	H3447_010_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3447	010	0	1	01	01	H3447_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	010	0	1	01	01	H3447_010_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3447	010	0	1	01	01	H3447_010_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	013	0	1	01	01	H3447_013_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	013	0	1	01	01	H3447_013_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	013	0	1	01	01	H3447_013_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3447	013	0	1	01	01	H3447_013_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	013	0	1	01	01	H3447_013_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	013	0	1	01	01	H3447_013_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	013	0	1	01	01	H3447_013_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	024	0	1	01	01	H3447_024_0	11			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	024	0	1	01	01	H3447_024_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	024	0	1	01	01	H3447_024_0	11			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	111.00	111.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3447	024	0	1	01	01	H3447_024_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					90.00	180.00	270.00					90.00	270.00	270.00																100.00				100.00			3.33	3.00	3.00			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	024	0	1	01	01	H3447_024_0	11			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	024	0	1	01	01	H3447_024_0	11			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	025	0	1	01	01	H3447_025_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	025	0	1	01	01	H3447_025_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	025	0	1	01	01	H3447_025_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3447	025	0	1	01	01	H3447_025_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	025	0	1	01	01	H3447_025_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	025	0	1	01	01	H3447_025_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	025	0	1	01	01	H3447_025_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	026	0	1	01	01	H3447_026_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	026	0	1	01	01	H3447_026_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	026	0	1	01	01	H3447_026_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	026	0	1	01	01	H3447_026_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	026	0	1	01	01	H3447_026_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3447	026	0	1	01	01	H3447_026_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3447	026	0	1	01	01	H3447_026_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	026	0	1	01	01	H3447_026_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3447	026	0	1	01	01	H3447_026_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	028	0	1	01	01	H3447_028_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	028	0	1	01	01	H3447_028_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		1															
H3447	028	0	1	01	01	H3447_028_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					10.00	20.00	30.00					0.00	0.00	0.00																10.00				10.00			0.33	0.33	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	028	0	1	01	01	H3447_028_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3447	028	0	1	01	01	H3447_028_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	028	0	1	01	01	H3447_028_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	028	0	1	01	01	H3447_028_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	028	0	1	01	01	H3447_028_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	033	0	1	01	01	H3447_033_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	033	0	1	01	01	H3447_033_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	033	0	1	01	01	H3447_033_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3447	033	0	1	01	01	H3447_033_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	033	0	1	01	01	H3447_033_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	033	0	1	01	01	H3447_033_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	033	0	1	01	01	H3447_033_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	037	0	1	01	01	H3447_037_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	037	0	1	01	01	H3447_037_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	037	0	1	01	01	H3447_037_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	037	0	1	01	01	H3447_037_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	037	0	1	01	01	H3447_037_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	037	0	1	01	01	H3447_037_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	037	0	1	01	01	H3447_037_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	037	0	1	01	01	H3447_037_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H3447	037	0	1	01	01	H3447_037_0	8			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	038	1	1	01	01	H3447_038_1	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	1	1	01	01	H3447_038_1	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	038	1	1	01	01	H3447_038_1	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	1	1	01	01	H3447_038_1	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	038	1	1	01	01	H3447_038_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	038	1	1	01	01	H3447_038_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	1	1	01	01	H3447_038_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	1	1	01	01	H3447_038_1	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	1	1	01	01	H3447_038_1	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	038	2	1	01	01	H3447_038_2	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	2	1	01	01	H3447_038_2	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	038	2	1	01	01	H3447_038_2	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	2	1	01	01	H3447_038_2	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	038	2	1	01	01	H3447_038_2	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	038	2	1	01	01	H3447_038_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	2	1	01	01	H3447_038_2	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	2	1	01	01	H3447_038_2	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	038	2	1	01	01	H3447_038_2	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	039	0	1	01	01	H3447_039_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	039	0	1	01	01	H3447_039_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	039	0	1	01	01	H3447_039_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3447	039	0	1	01	01	H3447_039_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	039	0	1	01	01	H3447_039_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	039	0	1	01	01	H3447_039_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	039	0	1	01	01	H3447_039_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	1	1	01	01	H3447_042_1	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	1	1	01	01	H3447_042_1	9			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	1	1	01	01	H3447_042_1	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	1	1	01	01	H3447_042_1	9			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	1	1	01	01	H3447_042_1	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	042	1	1	01	01	H3447_042_1	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	1	1	01	01	H3447_042_1	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	1	1	01	01	H3447_042_1	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	1	1	01	01	H3447_042_1	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	2	1	01	01	H3447_042_2	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	2	1	01	01	H3447_042_2	9			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	2	1	01	01	H3447_042_2	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	2	1	01	01	H3447_042_2	9			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	2	1	01	01	H3447_042_2	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	042	2	1	01	01	H3447_042_2	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	2	1	01	01	H3447_042_2	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	2	1	01	01	H3447_042_2	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	2	1	01	01	H3447_042_2	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	3	1	01	01	H3447_042_3	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	3	1	01	01	H3447_042_3	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	3	1	01	01	H3447_042_3	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	3	1	01	01	H3447_042_3	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	3	1	01	01	H3447_042_3	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	042	3	1	01	01	H3447_042_3	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	3	1	01	01	H3447_042_3	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	3	1	01	01	H3447_042_3	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	3	1	01	01	H3447_042_3	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	4	1	01	01	H3447_042_4	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	4	1	01	01	H3447_042_4	9			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	4	1	01	01	H3447_042_4	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	4	1	01	01	H3447_042_4	9			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	042	4	1	01	01	H3447_042_4	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	042	4	1	01	01	H3447_042_4	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	4	1	01	01	H3447_042_4	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	4	1	01	01	H3447_042_4	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	042	4	1	01	01	H3447_042_4	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	043	0	1	01	01	H3447_043_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	043	0	1	01	01	H3447_043_0	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3447	043	0	1	01	01	H3447_043_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	043	0	1	01	01	H3447_043_0	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H3447	043	0	1	01	01	H3447_043_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3447	043	0	1	01	01	H3447_043_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	043	0	1	01	01	H3447_043_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	043	0	1	01	01	H3447_043_0	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3447	043	0	1	01	01	H3447_043_0	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	023	1	1	02	01	H3449_023_1	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	023	1	1	02	01	H3449_023_1	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	023	1	1	02	01	H3449_023_1	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	023	1	1	02	01	H3449_023_1	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	023	1	1	02	01	H3449_023_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	1	1	02	01	H3449_023_1	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	1	1	02	01	H3449_023_1	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	023	2	1	02	01	H3449_023_2	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	023	2	1	02	01	H3449_023_2	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	023	2	1	02	01	H3449_023_2	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	023	2	1	02	01	H3449_023_2	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	023	2	1	02	01	H3449_023_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	2	1	02	01	H3449_023_2	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	2	1	02	01	H3449_023_2	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	023	4	1	02	01	H3449_023_4	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	023	4	1	02	01	H3449_023_4	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	023	4	1	02	01	H3449_023_4	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	023	4	1	02	01	H3449_023_4	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	023	4	1	02	01	H3449_023_4	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	4	1	02	01	H3449_023_4	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	4	1	02	01	H3449_023_4	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	023	5	1	02	01	H3449_023_5	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	023	5	1	02	01	H3449_023_5	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	023	5	1	02	01	H3449_023_5	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	023	5	1	02	01	H3449_023_5	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	023	5	1	02	01	H3449_023_5	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	5	1	02	01	H3449_023_5	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	023	5	1	02	01	H3449_023_5	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	024	1	1	02	01	H3449_024_1	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	024	1	1	02	01	H3449_024_1	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	024	1	1	02	01	H3449_024_1	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	024	1	1	02	01	H3449_024_1	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	024	1	1	02	01	H3449_024_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1264.74	33						1106.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	024	1	1	02	01	H3449_024_1	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	024	1	1	02	01	H3449_024_1	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	024	2	1	02	01	H3449_024_2	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	024	2	1	02	01	H3449_024_2	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	024	2	1	02	01	H3449_024_2	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	024	2	1	02	01	H3449_024_2	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	024	2	1	02	01	H3449_024_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1264.74	33						1106.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	024	2	1	02	01	H3449_024_2	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	024	2	1	02	01	H3449_024_2	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	024	3	1	02	01	H3449_024_3	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	024	3	1	02	01	H3449_024_3	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	024	3	1	02	01	H3449_024_3	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	024	3	1	02	01	H3449_024_3	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	024	3	1	02	01	H3449_024_3	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1264.74	33						1106.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	024	3	1	02	01	H3449_024_3	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	024	3	1	02	01	H3449_024_3	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								1.00	1.00	1.00					0.00	0.00	0.00											1.00	1.00	1.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	026	0	1	01	01	H3449_026_0	11			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	026	0	1	01	01	H3449_026_0	11			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	026	0	1	01	01	H3449_026_0	11			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	026	0	1	01	01	H3449_026_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	026	0	1	01	01	H3449_026_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	026	0	1	01	01	H3449_026_0	11			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	026	0	1	01	01	H3449_026_0	11			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	027	1	1	01	01	H3449_027_1	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	027	1	1	01	01	H3449_027_1	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	027	1	1	01	01	H3449_027_1	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	027	1	1	01	01	H3449_027_1	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	027	1	1	01	01	H3449_027_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											993.79	27						933.51	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	027	1	1	01	01	H3449_027_1	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	027	1	1	01	01	H3449_027_1	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3449	027	2	1	01	01	H3449_027_2	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H3449	027	2	1	01	01	H3449_027_2	10			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.20		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3449	027	2	1	01	01	H3449_027_2	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	90.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00	35.00		35.00
H3449	027	2	1	01	01	H3449_027_2	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	198.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3449	027	2	1	01	01	H3449_027_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											993.79	27						933.51	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	027	2	1	01	01	H3449_027_2	10			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3449	027	2	1	01	01	H3449_027_2	10			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3471	001	0	1	01	01	H3471_001_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	001	0	1	01	01	H3471_001_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	001	0	1	01	01	H3471_001_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	001	0	1	01	01	H3471_001_0	7			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	001	0	1	01	01	H3471_001_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				53.64	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	001	0	1	01	01	H3471_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	002	0	1	01	01	H3471_002_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	002	0	1	01	01	H3471_002_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	002	0	1	01	01	H3471_002_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	002	0	1	01	01	H3471_002_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	002	0	1	01	01	H3471_002_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				47.76	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	002	0	1	01	01	H3471_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	004	0	1	01	01	H3471_004_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	004	0	1	01	01	H3471_004_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	004	0	1	01	01	H3471_004_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	004	0	1	01	01	H3471_004_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	004	0	1	01	01	H3471_004_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				59.85	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	004	0	1	01	01	H3471_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	005	0	1	01	01	H3471_005_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	005	0	1	01	01	H3471_005_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	005	0	1	01	01	H3471_005_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	005	0	1	01	01	H3471_005_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	005	0	1	01	01	H3471_005_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				49.79	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	005	0	1	01	01	H3471_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	010	0	1	01	01	H3471_010_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	010	0	1	01	01	H3471_010_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	010	0	1	01	01	H3471_010_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	010	0	1	01	01	H3471_010_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	010	0	1	01	01	H3471_010_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				59.60	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	010	0	1	01	01	H3471_010_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	017	0	1	01	01	H3471_017_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	017	0	1	01	01	H3471_017_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	017	0	1	01	01	H3471_017_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	017	0	1	01	01	H3471_017_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	017	0	1	01	01	H3471_017_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				58.53	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	017	0	1	01	01	H3471_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	018	0	1	02	01	H3471_018_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	018	0	1	02	01	H3471_018_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	018	0	1	02	01	H3471_018_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	018	0	1	02	01	H3471_018_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	018	0	1	02	01	H3471_018_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				87.46	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	018	0	1	02	01	H3471_018_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	019	0	1	02	01	H3471_019_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3471	019	0	1	02	01	H3471_019_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3471	019	0	1	02	01	H3471_019_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00
H3471	019	0	1	02	01	H3471_019_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3471	019	0	1	02	01	H3471_019_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				58.60	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3471	019	0	1	02	01	H3471_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3499	002	0	1	01	01	H3499_002_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3499	002	0	1	01	01	H3499_002_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H3499	002	0	1	01	01	H3499_002_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3499	002	0	1	01	01	H3499_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H3499	002	0	1	01	01	H3499_002_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.76	50	50	50				81.76	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3499	002	0	1	01	01	H3499_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3499	002	0	1	01	01	H3499_002_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3499	002	0	1	01	01	H3499_002_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H3499	008	0	1	01	01	H3499_008_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3499	008	0	1	01	01	H3499_008_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3499	008	0	1	01	01	H3499_008_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H3499	008	0	1	01	01	H3499_008_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.05	48	48	48				98.05	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3499	008	0	1	01	01	H3499_008_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3499	008	0	1	01	01	H3499_008_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	010	0	1	02	01	H3528_010_0	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	010	0	1	02	01	H3528_010_0	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	010	0	1	02	01	H3528_010_0	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3528	010	0	1	02	01	H3528_010_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	010	0	1	02	01	H3528_010_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3528	010	0	1	02	01	H3528_010_0	12			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	010	0	1	02	01	H3528_010_0	12			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	011	1	1	02	01	H3528_011_1	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	1	1	02	01	H3528_011_1	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	1	1	02	01	H3528_011_1	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3528	011	1	1	02	01	H3528_011_1	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	1	1	02	01	H3528_011_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3528	011	1	1	02	01	H3528_011_1	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	1	1	02	01	H3528_011_1	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	011	2	1	02	01	H3528_011_2	11			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	2	1	02	01	H3528_011_2	11			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	2	1	02	01	H3528_011_2	11			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3528	011	2	1	02	01	H3528_011_2	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	2	1	02	01	H3528_011_2	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3528	011	2	1	02	01	H3528_011_2	11			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	011	2	1	02	01	H3528_011_2	11			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	014	0	1	02	01	H3528_014_0	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	014	0	1	02	01	H3528_014_0	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	014	0	1	02	01	H3528_014_0	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3528	014	0	1	02	01	H3528_014_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	014	0	1	02	01	H3528_014_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3528	014	0	1	02	01	H3528_014_0	12			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	014	0	1	02	01	H3528_014_0	12			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	015	0	1	02	01	H3528_015_0	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	015	0	1	02	01	H3528_015_0	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	015	0	1	02	01	H3528_015_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3528	015	0	1	02	01	H3528_015_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	015	0	1	02	01	H3528_015_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3528	015	0	1	02	01	H3528_015_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	015	0	1	02	01	H3528_015_0	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	016	0	1	02	01	H3528_016_0	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	016	0	1	02	01	H3528_016_0	10			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					2.00	4.00	6.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.07		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	016	0	1	02	01	H3528_016_0	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	016	0	1	02	01	H3528_016_0	10			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3528	016	0	1	02	01	H3528_016_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3528	016	0	1	02	01	H3528_016_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	016	0	1	02	01	H3528_016_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3528	016	0	1	02	01	H3528_016_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3528	016	0	1	02	01	H3528_016_0	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3533	006	0	1	01	01	H3533_006_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H3533	006	0	1	01	01	H3533_006_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3533	006	0	1	01	01	H3533_006_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H3533	006	0	1	01	01	H3533_006_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3533	006	0	1	01	01	H3533_006_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	006	0	1	01	01	H3533_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	006	0	1	01	01	H3533_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3533	010	0	1	01	01	H3533_010_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H3533	010	0	1	01	01	H3533_010_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H3533	010	0	1	01	01	H3533_010_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	010	0	1	01	01	H3533_010_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	010	0	1	01	01	H3533_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3533	013	0	1	01	01	H3533_013_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H3533	013	0	1	01	01	H3533_013_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3533	013	0	1	01	01	H3533_013_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H3533	013	0	1	01	01	H3533_013_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3533	013	0	1	01	01	H3533_013_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	013	0	1	01	01	H3533_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	013	0	1	01	01	H3533_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3533	027	0	1	01	01	H3533_027_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H3533	027	0	1	01	01	H3533_027_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	16.00		48.00																									20.00		60.00				16.00		0.00				16.00				16.00		0.53				0.67	0.53	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													16.00		48.00				20.00		60.00	16.00		0.00	16.00		16.00
H3533	027	0	1	01	01	H3533_027_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	027	0	1	01	01	H3533_027_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	027	0	1	01	01	H3533_027_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3533	032	1	1	01	01	H3533_032_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H3533	032	1	1	01	01	H3533_032_1	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H3533	032	1	1	01	01	H3533_032_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	032	1	1	01	01	H3533_032_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	032	1	1	01	01	H3533_032_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3533	032	2	1	01	01	H3533_032_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H3533	032	2	1	01	01	H3533_032_2	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H3533	032	2	1	01	01	H3533_032_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	032	2	1	01	01	H3533_032_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	032	2	1	01	01	H3533_032_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3533	033	0	1	01	01	H3533_033_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H3533	033	0	1	01	01	H3533_033_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H3533	033	0	1	01	01	H3533_033_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	033	0	1	01	01	H3533_033_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H3533	033	0	1	01	01	H3533_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H3536	002	0	1	01	01	H3536_002_0	9			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	002	0	1	01	01	H3536_002_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	002	0	1	01	01	H3536_002_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H3536	002	0	1	01	01	H3536_002_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	002	0	1	01	01	H3536_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	002	0	1	01	01	H3536_002_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	002	0	1	01	01	H3536_002_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3536	004	0	1	01	01	H3536_004_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					5.00	15.00	15.00																10.00				10.00			0.33	0.17	0.17			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	004	0	1	01	01	H3536_004_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					15.00	45.00	45.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	004	0	1	01	01	H3536_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								39.00	78.00	117.00					39.00	78.00	117.00					39.00	117.00	117.00																39.00				39.00			1.30	1.30	1.30			1.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H3536	004	0	1	01	01	H3536_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	004	0	1	01	01	H3536_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	004	0	1	01	01	H3536_004_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	15.00	15.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	006	0	1	01	01	H3536_006_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	006	0	1	01	01	H3536_006_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	006	0	1	01	01	H3536_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3536	006	0	1	01	01	H3536_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								99.00	198.00	297.00					94.00	188.00	282.00					94.00	188.00	188.00																99.00				99.00			3.30	3.13	3.13			2.91	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	006	0	1	01	01	H3536_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	006	0	1	01	01	H3536_006_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3536	006	0	1	01	01	H3536_006_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3551	001	0	1	01	01	H3551_001_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	001	0	1	01	01	H3551_001_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		15.00																			5.00		5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	001	0	1	01	01	H3551_001_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	45.00		135.00																			45.00		45.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		35.00				35.00		35.00
H3551	001	0	1	01	01	H3551_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	001	0	1	01	01	H3551_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	002	0	1	01	01	H3551_002_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	002	0	1	01	01	H3551_002_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	5.00		15.00																			5.00		5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	002	0	1	01	01	H3551_002_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	45.00		135.00																			45.00		45.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		35.00				35.00		35.00
H3551	002	0	1	01	01	H3551_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3551	002	0	1	01	01	H3551_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3554	002	0	1	04	01	H3554_002_0	5			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3554	002	0	1	04	01	H3554_002_0	5			Generic	4	11	3	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	15.00		30.00																			15.00		0.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3554	002	0	1	04	01	H3554_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00		60.00				20.00		60.00				20.00		20.00
H3554	002	0	1	04	01	H3554_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				1	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00		60.00				20.00		60.00				20.00		20.00
H3554	002	0	1	04	01	H3554_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				910.40	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00						20.00						20.00		20.00
H3554	002	0	1	04	01	H3554_002_0	5			Select Care Drugs	4	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3554	002	0	1	04	01	H3554_002_0	5			Select Care Drugs	4	11	1	2	6	3	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3554	007	0	1	04	01	H3554_007_0	4			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	1.00		2.00																			1.00		0.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3554	007	0	1	04	01	H3554_007_0	4			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		100				1	2	30		100				30		31	1.00		2.00																			1.00		0.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3554	007	0	1	04	01	H3554_007_0	4			Generic	4	11	3	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	10.00		20.00																			10.00		0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3554	007	0	1	04	01	H3554_007_0	4			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H3554	007	0	1	04	01	H3554_007_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				1	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H3554	007	0	1	04	01	H3554_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				852.41	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3554	007	0	1	04	01	H3554_007_0	4			Select Care Drugs	4	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3554	007	0	1	04	01	H3554_007_0	4			Select Care Drugs	4	11	1	2	6	3	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3557	001	0	1	04	01	H3557_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					0.00	0.00				8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00		16.00	24.00		0.00	0.00	8.00		0.00
H3557	001	0	1	04	01	H3557_001_0	9			Preferred Generic	4	01	1	2	1	3		111	01		101	1				30	60	90	1	2					60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					0.00	0.00				8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3557	001	0	1	04	01	H3557_001_0	9			Generic	4	01	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								16.00	32.00	48.00					0.00	0.00	0.00												32.00	48.00					0.00	0.00				16.00				0.00			0.53	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													16.00	32.00	48.00	0.00	0.00	0.00		32.00	48.00		0.00	0.00	16.00		0.00
H3557	001	0	1	04	01	H3557_001_0	9			Generic	4	01	1	2	2	3		111	01		101	1				30	60	90	1	2					60	90	30		31								16.00	32.00	48.00					0.00	0.00	0.00												32.00	48.00					0.00	0.00				16.00				0.00			0.53	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3557	001	0	1	04	01	H3557_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					94.00	117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00		40.00	60.00		40.00	50.00	20.00		20.00
H3557	001	0	1	04	01	H3557_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	250.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00
H3557	001	0	1	04	01	H3557_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	001	0	1	01	01	H3597_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	001	0	1	01	01	H3597_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	001	0	1	01	01	H3597_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	001	0	1	01	01	H3597_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	001	0	1	01	01	H3597_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3597	001	0	1	01	01	H3597_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	001	0	1	01	01	H3597_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											845.65	33						667.63	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3597	007	0	1	01	01	H3597_007_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	007	0	1	01	01	H3597_007_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	007	0	1	01	01	H3597_007_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	007	0	1	01	01	H3597_007_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	007	0	1	01	01	H3597_007_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3597	007	0	1	01	01	H3597_007_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	007	0	1	01	01	H3597_007_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											683.01	33						589.09	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3597	009	0	1	01	01	H3597_009_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	009	0	1	01	01	H3597_009_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	009	0	1	01	01	H3597_009_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	009	0	1	01	01	H3597_009_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	009	0	1	01	01	H3597_009_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3597	009	0	1	01	01	H3597_009_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	009	0	1	01	01	H3597_009_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											803.47	30						627.30	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3597	014	0	1	01	01	H3597_014_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	014	0	1	01	01	H3597_014_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	014	0	1	01	01	H3597_014_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	014	0	1	01	01	H3597_014_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3597	014	0	1	01	01	H3597_014_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.22	25	25	25				47.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3597	014	0	1	01	01	H3597_014_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.33	50	50	50				63.86	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3597	014	0	1	01	01	H3597_014_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											994.95	33						686.02	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3653	004	0	1	02	01	H3653_004_0	9			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	004	0	1	02	01	H3653_004_0	9			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	004	0	1	02	01	H3653_004_0	9			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	004	0	1	02	01	H3653_004_0	9			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	004	0	1	02	01	H3653_004_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	42.00		126.00																			42.00		84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	004	0	1	02	01	H3653_004_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	004	0	1	02	01	H3653_004_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1109.31	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H3653	015	0	1	02	01	H3653_015_0	8			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	015	0	1	02	01	H3653_015_0	8			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	015	0	1	02	01	H3653_015_0	8			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	015	0	1	02	01	H3653_015_0	8			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	015	0	1	02	01	H3653_015_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	015	0	1	02	01	H3653_015_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	015	0	1	02	01	H3653_015_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				898.66	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H3653	022	0	1	02	01	H3653_022_0	8			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	022	0	1	02	01	H3653_022_0	8			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	022	0	1	02	01	H3653_022_0	8			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	022	0	1	02	01	H3653_022_0	8			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	022	0	1	02	01	H3653_022_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	022	0	1	02	01	H3653_022_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	022	0	1	02	01	H3653_022_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1308.02	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H3653	024	0	1	02	01	H3653_024_0	9			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	024	0	1	02	01	H3653_024_0	9			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	024	0	1	02	01	H3653_024_0	9			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	024	0	1	02	01	H3653_024_0	9			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	024	0	1	02	01	H3653_024_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	024	0	1	02	01	H3653_024_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	024	0	1	02	01	H3653_024_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1090.01	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H3653	026	0	1	02	01	H3653_026_0	8			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	026	0	1	02	01	H3653_026_0	8			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	026	0	1	02	01	H3653_026_0	8			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	026	0	1	02	01	H3653_026_0	8			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	026	0	1	02	01	H3653_026_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	026	0	1	02	01	H3653_026_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	026	0	1	02	01	H3653_026_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1007.45	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H3653	027	0	1	02	01	H3653_027_0	8			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	027	0	1	02	01	H3653_027_0	8			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	027	0	1	02	01	H3653_027_0	8			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H3653	027	0	1	02	01	H3653_027_0	8			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3653	027	0	1	02	01	H3653_027_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	027	0	1	02	01	H3653_027_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H3653	027	0	1	02	01	H3653_027_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				990.55	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H3655	034	0	1	01	01	H3655_034_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								7.00	14.00	21.00					2.00	4.00	6.00					0.00	0.00	0.00																7.00				7.00			0.23	0.07	0.00			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	034	0	1	01	01	H3655_034_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	034	0	1	01	01	H3655_034_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	74.00	74.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3655	034	0	1	01	01	H3655_034_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	180.00																100.00				100.00			3.33	3.00	3.00			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	034	0	1	01	01	H3655_034_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	034	0	1	01	01	H3655_034_0	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	034	0	1	01	01	H3655_034_0	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	041	0	1	01	01	H3655_041_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	041	0	1	01	01	H3655_041_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	041	0	1	01	01	H3655_041_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3655	041	0	1	01	01	H3655_041_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	041	0	1	01	01	H3655_041_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	041	0	1	01	01	H3655_041_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	042	0	1	01	01	H3655_042_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	042	0	1	01	01	H3655_042_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	042	0	1	01	01	H3655_042_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3655	042	0	1	01	01	H3655_042_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	042	0	1	01	01	H3655_042_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	042	0	1	01	01	H3655_042_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	042	0	1	01	01	H3655_042_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	1	1	01	01	H3655_045_1	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	1	1	01	01	H3655_045_1	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	1	1	01	01	H3655_045_1	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	1	1	01	01	H3655_045_1	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	1	1	01	01	H3655_045_1	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H3655	045	1	1	01	01	H3655_045_1	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	1	1	01	01	H3655_045_1	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	1	1	01	01	H3655_045_1	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	1	1	01	01	H3655_045_1	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	2	1	01	01	H3655_045_2	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	2	1	01	01	H3655_045_2	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	2	1	01	01	H3655_045_2	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	2	1	01	01	H3655_045_2	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	2	1	01	01	H3655_045_2	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H3655	045	2	1	01	01	H3655_045_2	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	2	1	01	01	H3655_045_2	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	2	1	01	01	H3655_045_2	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	2	1	01	01	H3655_045_2	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	3	1	01	01	H3655_045_3	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	3	1	01	01	H3655_045_3	9			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	3	1	01	01	H3655_045_3	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	3	1	01	01	H3655_045_3	9			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	3	1	01	01	H3655_045_3	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H3655	045	3	1	01	01	H3655_045_3	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	3	1	01	01	H3655_045_3	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	3	1	01	01	H3655_045_3	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	3	1	01	01	H3655_045_3	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	4	1	01	01	H3655_045_4	14			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	4	1	01	01	H3655_045_4	14			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	4	1	01	01	H3655_045_4	14			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	4	1	01	01	H3655_045_4	14			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	045	4	1	01	01	H3655_045_4	14			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H3655	045	4	1	01	01	H3655_045_4	14			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	4	1	01	01	H3655_045_4	14			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	4	1	01	01	H3655_045_4	14			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	045	4	1	01	01	H3655_045_4	14			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	047	0	1	01	01	H3655_047_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	047	0	1	01	01	H3655_047_0	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3655	047	0	1	01	01	H3655_047_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	047	0	1	01	01	H3655_047_0	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H3655	047	0	1	01	01	H3655_047_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3655	047	0	1	01	01	H3655_047_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	047	0	1	01	01	H3655_047_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	047	0	1	01	01	H3655_047_0	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3655	047	0	1	01	01	H3655_047_0	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	028	0	1	02	01	H3660_028_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	028	0	1	02	01	H3660_028_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	028	0	1	02	01	H3660_028_0	7			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	028	0	1	02	01	H3660_028_0	7			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	39.00		97.50																					97.50																39.00				39.00		1.30						1.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		97.50						97.50				35.00		35.00
H3660	028	0	1	02	01	H3660_028_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	95.00		285.00																					285.00																95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	028	0	1	02	01	H3660_028_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	028	0	1	02	01	H3660_028_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	028	0	1	02	01	H3660_028_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	029	0	1	02	01	H3660_029_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	029	0	1	02	01	H3660_029_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	029	0	1	02	01	H3660_029_0	7			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	029	0	1	02	01	H3660_029_0	7			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	44.00		110.00																					110.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	029	0	1	02	01	H3660_029_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	029	0	1	02	01	H3660_029_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	029	0	1	02	01	H3660_029_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	029	0	1	02	01	H3660_029_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	044	0	1	01	01	H3660_044_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	044	0	1	01	01	H3660_044_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	044	0	1	01	01	H3660_044_0	7			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	044	0	1	01	01	H3660_044_0	7			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	44.00		110.00																					110.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	044	0	1	01	01	H3660_044_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	044	0	1	01	01	H3660_044_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	044	0	1	01	01	H3660_044_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	044	0	1	01	01	H3660_044_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	050	0	1	01	01	H3660_050_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	050	0	1	01	01	H3660_050_0	9			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	050	0	1	01	01	H3660_050_0	9			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	9.00		22.50																					22.50																9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00		22.50						22.50				9.00		9.00
H3660	050	0	1	01	01	H3660_050_0	9			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	46.00		115.00																					115.00																46.00				46.00		1.53						1.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	050	0	1	01	01	H3660_050_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	050	0	1	01	01	H3660_050_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	050	0	1	01	01	H3660_050_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	050	0	1	01	01	H3660_050_0	9			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	053	1	1	01	01	H3660_053_1	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	053	1	1	01	01	H3660_053_1	9			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	053	1	1	01	01	H3660_053_1	9			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	053	1	1	01	01	H3660_053_1	9			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	44.00		110.00																					110.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	053	1	1	01	01	H3660_053_1	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	053	1	1	01	01	H3660_053_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	053	1	1	01	01	H3660_053_1	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	053	1	1	01	01	H3660_053_1	9			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	053	2	1	01	01	H3660_053_2	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	053	2	1	01	01	H3660_053_2	9			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	053	2	1	01	01	H3660_053_2	9			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	053	2	1	01	01	H3660_053_2	9			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	44.00		110.00																					110.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	053	2	1	01	01	H3660_053_2	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	053	2	1	01	01	H3660_053_2	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	053	2	1	01	01	H3660_053_2	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	053	2	1	01	01	H3660_053_2	9			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	056	1	1	01	01	H3660_056_1	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	056	1	1	01	01	H3660_056_1	9			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	056	1	1	01	01	H3660_056_1	9			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	056	1	1	01	01	H3660_056_1	9			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	44.00		110.00																					110.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	056	1	1	01	01	H3660_056_1	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	056	1	1	01	01	H3660_056_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	056	1	1	01	01	H3660_056_1	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	056	1	1	01	01	H3660_056_1	9			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	056	2	1	01	01	H3660_056_2	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	056	2	1	01	01	H3660_056_2	10			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3660	056	2	1	01	01	H3660_056_2	10			Generic	4	11	1	2	2	1	110		01	100		1	30		90				1	2			90				30		31	8.00		20.00																					20.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													8.00		20.00						20.00				8.00		8.00
H3660	056	2	1	01	01	H3660_056_2	10			Preferred Brand	4	11	3	2	3	1	110		01	100		1	30		90				1	2			90				30		31	44.00		110.00																					110.00																44.00				44.00		1.47						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	056	2	1	01	01	H3660_056_2	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				1	2			90				30		31	100.00		300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00						105.00				35.00		35.00
H3660	056	2	1	01	01	H3660_056_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3660	056	2	1	01	01	H3660_056_2	10			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3660	056	2	1	01	01	H3660_056_2	10			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3664	017	0	1	02	01	H3664_017_0	13			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	017	0	1	02	01	H3664_017_0	13			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	017	0	1	02	01	H3664_017_0	13			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								16.00	32.00	48.00					8.00	16.00	24.00					8.00	16.00	20.00																16.00				8.00			0.53	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	017	0	1	02	01	H3664_017_0	13			Generic	4	01	1	2	2	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								16.00	32.00	48.00					8.00	16.00	24.00					8.00	16.00	20.00																16.00				8.00			0.53	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	017	0	1	02	01	H3664_017_0	13			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					45.00	90.00	125.00																47.00				42.00			1.57	1.40	1.50			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3664	017	0	1	02	01	H3664_017_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	275.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	017	0	1	02	01	H3664_017_0	13			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1062.82	33						1062.82	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	020	0	1	02	01	H3664_020_0	13			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	020	0	1	02	01	H3664_020_0	13			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	020	0	1	02	01	H3664_020_0	13			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					8.00	16.00	24.00					8.00	16.00	20.00																18.00				8.00			0.60	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	020	0	1	02	01	H3664_020_0	13			Generic	4	01	1	2	2	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					8.00	16.00	24.00					8.00	16.00	20.00																18.00				8.00			0.60	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	020	0	1	02	01	H3664_020_0	13			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					45.00	90.00	125.00																47.00				42.00			1.57	1.40	1.50			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3664	020	0	1	02	01	H3664_020_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	275.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	020	0	1	02	01	H3664_020_0	13			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1931.59	33						1931.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	021	0	1	02	01	H3664_021_0	13			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	021	0	1	02	01	H3664_021_0	13			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	021	0	1	02	01	H3664_021_0	13			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					15.00	30.00	45.00					15.00	30.00	45.00																20.00				15.00			0.67	0.50	0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	021	0	1	02	01	H3664_021_0	13			Generic	4	01	1	2	2	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					15.00	30.00	45.00					15.00	30.00	45.00																20.00				15.00			0.67	0.50	0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	021	0	1	02	01	H3664_021_0	13			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					45.00	90.00	125.00																47.00				42.00			1.57	1.40	1.50			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3664	021	0	1	02	01	H3664_021_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	021	0	1	02	01	H3664_021_0	13			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1505.17	33						1505.17	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	023	0	1	02	01	H3664_023_0	13			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	023	0	1	02	01	H3664_023_0	13			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	023	0	1	02	01	H3664_023_0	13			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					15.00	30.00	45.00					15.00	30.00	45.00																20.00				15.00			0.67	0.50	0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	023	0	1	02	01	H3664_023_0	13			Generic	4	01	1	2	2	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					15.00	30.00	45.00					15.00	30.00	45.00																20.00				15.00			0.67	0.50	0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3664	023	0	1	02	01	H3664_023_0	13			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					45.00	90.00	125.00																47.00				42.00			1.57	1.40	1.50			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3664	023	0	1	02	01	H3664_023_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																100.00				95.00			3.33	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3664	023	0	1	02	01	H3664_023_0	13			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1505.17	33						1505.17	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3668	018	1	1	01	01	H3668_018_1	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	018	1	1	01	01	H3668_018_1	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	018	1	1	01	01	H3668_018_1	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H3668	018	1	1	01	01	H3668_018_1	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	018	1	1	01	01	H3668_018_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	75.00	150.00	225.00																			75.00	150.00	150.00																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	018	1	1	01	01	H3668_018_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	018	2	1	01	01	H3668_018_2	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	018	2	1	01	01	H3668_018_2	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	018	2	1	01	01	H3668_018_2	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H3668	018	2	1	01	01	H3668_018_2	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	018	2	1	01	01	H3668_018_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	75.00	150.00	225.00																			75.00	150.00	150.00																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	018	2	1	01	01	H3668_018_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	019	1	1	01	01	H3668_019_1	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	019	1	1	01	01	H3668_019_1	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	019	1	1	01	01	H3668_019_1	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H3668	019	1	1	01	01	H3668_019_1	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	019	1	1	01	01	H3668_019_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	019	1	1	01	01	H3668_019_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	019	2	1	01	01	H3668_019_2	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	019	2	1	01	01	H3668_019_2	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	019	2	1	01	01	H3668_019_2	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H3668	019	2	1	01	01	H3668_019_2	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	019	2	1	01	01	H3668_019_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	019	2	1	01	01	H3668_019_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	020	0	1	01	01	H3668_020_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	020	0	1	01	01	H3668_020_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	020	0	1	01	01	H3668_020_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H3668	020	0	1	01	01	H3668_020_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	020	0	1	01	01	H3668_020_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	75.00	150.00	225.00																			75.00	150.00	150.00																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	020	0	1	01	01	H3668_020_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	022	0	1	01	01	H3668_022_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	022	0	1	01	01	H3668_022_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	022	0	1	01	01	H3668_022_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H3668	022	0	1	01	01	H3668_022_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	022	0	1	01	01	H3668_022_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	75.00	150.00	225.00																			75.00	150.00	150.00																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	022	0	1	01	01	H3668_022_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	023	0	1	01	01	H3668_023_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	023	0	1	01	01	H3668_023_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	023	0	1	01	01	H3668_023_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H3668	023	0	1	01	01	H3668_023_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	023	0	1	01	01	H3668_023_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	75.00	150.00	225.00																			75.00	150.00	150.00																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	023	0	1	01	01	H3668_023_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	025	0	1	01	01	H3668_025_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	025	0	1	01	01	H3668_025_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	025	0	1	01	01	H3668_025_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	025	0	1	01	01	H3668_025_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	025	0	1	01	01	H3668_025_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	025	0	1	01	01	H3668_025_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	026	0	1	01	01	H3668_026_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	026	0	1	01	01	H3668_026_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	026	0	1	01	01	H3668_026_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	026	0	1	01	01	H3668_026_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	026	0	1	01	01	H3668_026_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	026	0	1	01	01	H3668_026_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	030	0	1	01	01	H3668_030_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	030	0	1	01	01	H3668_030_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	030	0	1	01	01	H3668_030_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H3668	030	0	1	01	01	H3668_030_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	030	0	1	01	01	H3668_030_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	030	0	1	01	01	H3668_030_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3668	031	0	1	01	01	H3668_031_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3668	031	0	1	01	01	H3668_031_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3668	031	0	1	01	01	H3668_031_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H3668	031	0	1	01	01	H3668_031_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	031	0	1	01	01	H3668_031_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3668	031	0	1	01	01	H3668_031_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3672	013	0	1	01	01	H3672_013_0	13			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					0.00	0.00	0.00											13.00	26.00	39.00				0.00	0.00	0.00				13.00				13.00			0.43	0.00		0.43	0.00	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3672	013	0	1	01	01	H3672_013_0	13			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	0.00		0.00
H3672	013	0	1	01	01	H3672_013_0	13			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3672	013	0	1	01	01	H3672_013_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3672	013	0	1	01	01	H3672_013_0	13			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	33						1000.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3672	020	0	1	01	01	H3672_020_0	13			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					0.00	0.00	0.00											13.00	26.00	39.00				0.00	0.00	0.00				13.00				13.00			0.43	0.00		0.43	0.00	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3672	020	0	1	01	01	H3672_020_0	13			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3672	020	0	1	01	01	H3672_020_0	13			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3672	020	0	1	01	01	H3672_020_0	13			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3672	020	0	1	01	01	H3672_020_0	13			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	33						1000.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3672	023	0	1	01	01	H3672_023_0	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					0.00	0.00	0.00											13.00	26.00	39.00				0.00	0.00	0.00				13.00				13.00			0.43	0.00		0.43	0.00	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3672	023	0	1	01	01	H3672_023_0	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3672	023	0	1	01	01	H3672_023_0	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3672	023	0	1	01	01	H3672_023_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3672	023	0	1	01	01	H3672_023_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	33						1000.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	001	0	1	01	01	H3706_001_0	5			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	001	0	1	01	01	H3706_001_0	5			Preferred Generic	4	11	3	2	1	3		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3706	001	0	1	01	01	H3706_001_0	5			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	1				30		100	30		31								15.00		45.00					10.00		0.00											15.00		45.00				10.00		0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	001	0	1	01	01	H3706_001_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		84.00	35.00		105.00	35.00		84.00	35.00		35.00
H3706	001	0	1	01	01	H3706_001_0	5			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H3706	001	0	1	01	01	H3706_001_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		100	1	1				30		100	30		31								100.00		300.00					90.00		270.00											100.00		300.00				90.00		270.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H3706	001	0	1	01	01	H3706_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1654.76	33						699.32	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3706	023	0	1	01	01	H3706_023_0	5			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	023	0	1	01	01	H3706_023_0	5			Preferred Generic	4	11	3	2	1	3		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3706	023	0	1	01	01	H3706_023_0	5			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	1				30		100	30		31								15.00		45.00					10.00		0.00											15.00		45.00				10.00		0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	023	0	1	01	01	H3706_023_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		84.00	35.00		105.00	35.00		84.00	35.00		35.00
H3706	023	0	1	01	01	H3706_023_0	5			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H3706	023	0	1	01	01	H3706_023_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		100	1	1				30		100	30		31								100.00		300.00					90.00		270.00											100.00		300.00				90.00		270.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H3706	023	0	1	01	01	H3706_023_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1727.97	33						799.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3706	024	0	1	01	01	H3706_024_0	4			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	024	0	1	01	01	H3706_024_0	4			Preferred Generic	4	11	3	2	1	3		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3706	024	0	1	01	01	H3706_024_0	4			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	1				30		100	30		31								10.00		30.00					5.00		0.00											10.00		30.00				5.00		0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	024	0	1	01	01	H3706_024_0	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		84.00	35.00		105.00	35.00		84.00	35.00		35.00
H3706	024	0	1	01	01	H3706_024_0	4			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H3706	024	0	1	01	01	H3706_024_0	4			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		100	1	1				30		100	30		31								100.00		300.00					90.00		270.00											100.00		300.00				90.00		270.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H3706	024	0	1	01	01	H3706_024_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1074.15	33						966.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3706	025	0	1	01	01	H3706_025_0	6			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	025	0	1	01	01	H3706_025_0	6			Preferred Generic	4	11	3	2	1	3		110	01		110	1				30		100	1	1				30		100	30		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3706	025	0	1	01	01	H3706_025_0	6			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	1				30		100	30		31								10.00		30.00					5.00		0.00											10.00		30.00				5.00		0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3706	025	0	1	01	01	H3706_025_0	6			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		84.00	35.00		105.00	35.00		84.00	35.00		35.00
H3706	025	0	1	01	01	H3706_025_0	6			Preferred Brand	4	11	1	2	3	3		110	01		110	1				30		100	1	1				30		100	30		31								47.00		141.00					42.00		84.00											47.00		141.00				42.00		84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H3706	025	0	1	01	01	H3706_025_0	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		100	1	1				30		100	30		31								100.00		300.00					90.00		270.00											100.00		300.00				90.00		270.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H3706	025	0	1	01	01	H3706_025_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1004.16	33						937.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35		35
H3727	001	1	1	01	01	H3727_001_1	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			5.00	10.00	15.00																6.00				6.00		0.20			0.17			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	1	1	01	01	H3727_001_1	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	17.00	34.00	51.00																			15.00	30.00	45.00																17.00				17.00		0.57			0.50			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	1	1	01	01	H3727_001_1	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			40.00	80.00	120.00																45.00				45.00		1.50			1.33			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	001	1	1	01	01	H3727_001_1	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	92.00	184.00	276.00																			90.00	180.00	270.00																92.00				92.00		3.07			3.00			2.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	1	1	01	01	H3727_001_1	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	2	1	01	01	H3727_001_2	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			5.00	10.00	15.00																6.00				6.00		0.20			0.17			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	2	1	01	01	H3727_001_2	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	17.00	34.00	51.00																			15.00	30.00	45.00																17.00				17.00		0.57			0.50			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	2	1	01	01	H3727_001_2	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			40.00	80.00	120.00																45.00				45.00		1.50			1.33			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	001	2	1	01	01	H3727_001_2	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	92.00	184.00	276.00																			90.00	180.00	270.00																92.00				92.00		3.07			3.00			2.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	2	1	01	01	H3727_001_2	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	3	1	01	01	H3727_001_3	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			5.00	10.00	15.00																6.00				6.00		0.20			0.17			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	3	1	01	01	H3727_001_3	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	17.00	34.00	51.00																			15.00	30.00	45.00																17.00				17.00		0.57			0.50			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	3	1	01	01	H3727_001_3	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			40.00	80.00	120.00																45.00				45.00		1.50			1.33			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	001	3	1	01	01	H3727_001_3	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	92.00	184.00	276.00																			90.00	180.00	270.00																92.00				92.00		3.07			3.00			2.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	001	3	1	01	01	H3727_001_3	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	1	1	01	01	H3727_004_1	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	1	1	01	01	H3727_004_1	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	24.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	1	1	01	01	H3727_004_1	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	004	1	1	01	01	H3727_004_1	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	1	1	01	01	H3727_004_1	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	2	1	01	01	H3727_004_2	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	2	1	01	01	H3727_004_2	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	24.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	2	1	01	01	H3727_004_2	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	004	2	1	01	01	H3727_004_2	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	2	1	01	01	H3727_004_2	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	3	1	01	01	H3727_004_3	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	3	1	01	01	H3727_004_3	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	16.00	24.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	3	1	01	01	H3727_004_3	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	004	3	1	01	01	H3727_004_3	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	004	3	1	01	01	H3727_004_3	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	1	1	01	01	H3727_005_1	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	1	1	01	01	H3727_005_1	5			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3727	005	1	1	01	01	H3727_005_1	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	1	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	1	1	01	01	H3727_005_1	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	005	1	1	01	01	H3727_005_1	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	1	1	01	01	H3727_005_1	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	2	1	01	01	H3727_005_2	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	2	1	01	01	H3727_005_2	5			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3727	005	2	1	01	01	H3727_005_2	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	1	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	2	1	01	01	H3727_005_2	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	005	2	1	01	01	H3727_005_2	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	2	1	01	01	H3727_005_2	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	3	1	01	01	H3727_005_3	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	3	1	01	01	H3727_005_3	5			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3727	005	3	1	01	01	H3727_005_3	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	1	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	3	1	01	01	H3727_005_3	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3727	005	3	1	01	01	H3727_005_3	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3727	005	3	1	01	01	H3727_005_3	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	001	0	1	02	01	H3748_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	001	0	1	02	01	H3748_001_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	001	0	1	02	01	H3748_001_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	001	0	1	02	01	H3748_001_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	001	0	1	02	01	H3748_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	001	0	1	02	01	H3748_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	001	0	1	02	01	H3748_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.52	30						617.42	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	003	0	1	02	01	H3748_003_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	003	0	1	02	01	H3748_003_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	003	0	1	02	01	H3748_003_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	003	0	1	02	01	H3748_003_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	003	0	1	02	01	H3748_003_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	003	0	1	02	01	H3748_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	003	0	1	02	01	H3748_003_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.43	33						678.41	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	004	0	1	02	01	H3748_004_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	004	0	1	02	01	H3748_004_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	004	0	1	02	01	H3748_004_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	004	0	1	02	01	H3748_004_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	004	0	1	02	01	H3748_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	004	0	1	02	01	H3748_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	004	0	1	02	01	H3748_004_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											736.88	30						819.54	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	006	0	1	02	01	H3748_006_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	006	0	1	02	01	H3748_006_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	006	0	1	02	01	H3748_006_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	006	0	1	02	01	H3748_006_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	006	0	1	02	01	H3748_006_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	006	0	1	02	01	H3748_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	006	0	1	02	01	H3748_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											896.95	33						691.44	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	007	0	1	02	01	H3748_007_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	007	0	1	02	01	H3748_007_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	007	0	1	02	01	H3748_007_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	007	0	1	02	01	H3748_007_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	007	0	1	02	01	H3748_007_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	007	0	1	02	01	H3748_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	007	0	1	02	01	H3748_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											770.33	33						590.84	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	008	0	1	02	01	H3748_008_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	008	0	1	02	01	H3748_008_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	008	0	1	02	01	H3748_008_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	008	0	1	02	01	H3748_008_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	008	0	1	02	01	H3748_008_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	008	0	1	02	01	H3748_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	008	0	1	02	01	H3748_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											824.63	30						607.45	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	009	0	1	02	01	H3748_009_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	009	0	1	02	01	H3748_009_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	009	0	1	02	01	H3748_009_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	009	0	1	02	01	H3748_009_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	009	0	1	02	01	H3748_009_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	009	0	1	02	01	H3748_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	009	0	1	02	01	H3748_009_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											757.02	33						827.12	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	010	0	1	02	01	H3748_010_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	010	0	1	02	01	H3748_010_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	010	0	1	02	01	H3748_010_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	010	0	1	02	01	H3748_010_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	010	0	1	02	01	H3748_010_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	010	0	1	02	01	H3748_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	010	0	1	02	01	H3748_010_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											844.91	30						588.18	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3748	013	0	1	02	01	H3748_013_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	013	0	1	02	01	H3748_013_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	013	0	1	02	01	H3748_013_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	013	0	1	02	01	H3748_013_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3748	013	0	1	02	01	H3748_013_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.91	25	25	25				75.64	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3748	013	0	1	02	01	H3748_013_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.45	50	50	50				25.99	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3748	013	0	1	02	01	H3748_013_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											918.85	33						648.13	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3749	001	0	1	02	01	H3749_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	001	0	1	02	01	H3749_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3749	001	0	1	02	01	H3749_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	001	0	1	02	01	H3749_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3749	001	0	1	02	01	H3749_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	001	0	1	02	01	H3749_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	001	0	1	02	01	H3749_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				462.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	017	0	1	02	01	H3749_017_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	017	0	1	02	01	H3749_017_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3749	017	0	1	02	01	H3749_017_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	017	0	1	02	01	H3749_017_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3749	017	0	1	02	01	H3749_017_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	017	0	1	02	01	H3749_017_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	017	0	1	02	01	H3749_017_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				570.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	018	0	1	02	01	H3749_018_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	018	0	1	02	01	H3749_018_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3749	018	0	1	02	01	H3749_018_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	018	0	1	02	01	H3749_018_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3749	018	0	1	02	01	H3749_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	018	0	1	02	01	H3749_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	018	0	1	02	01	H3749_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				543.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	020	0	1	02	01	H3749_020_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	020	0	1	02	01	H3749_020_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3749	020	0	1	02	01	H3749_020_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3749	020	0	1	02	01	H3749_020_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3749	020	0	1	02	01	H3749_020_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	020	0	1	02	01	H3749_020_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3749	020	0	1	02	01	H3749_020_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				591.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3755	001	0	1	01	01	H3755_001_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3755	001	0	1	01	01	H3755_001_0	4			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3755	001	0	1	01	01	H3755_001_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H3755	001	0	1	01	01	H3755_001_0	4			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3755	001	0	1	01	01	H3755_001_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3755	001	0	1	01	01	H3755_001_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3755	001	0	1	01	01	H3755_001_0	4			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1771.52	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3755	004	0	1	01	01	H3755_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3755	004	0	1	01	01	H3755_004_0	5			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3755	004	0	1	01	01	H3755_004_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H3755	004	0	1	01	01	H3755_004_0	5			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3755	004	0	1	01	01	H3755_004_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3755	004	0	1	01	01	H3755_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3755	004	0	1	01	01	H3755_004_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1495.63	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3755	005	0	1	01	01	H3755_005_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3755	005	0	1	01	01	H3755_005_0	4			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3755	005	0	1	01	01	H3755_005_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H3755	005	0	1	01	01	H3755_005_0	4			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3755	005	0	1	01	01	H3755_005_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3755	005	0	1	01	01	H3755_005_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3755	005	0	1	01	01	H3755_005_0	4			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1418.86	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3777	001	2	1	01	01	H3777_001_2	9			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H3777	001	2	1	01	01	H3777_001_2	9			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	5.00	10.00	15.00																									5.00	10.00	15.00				5.00	10.00	12.50				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00	5.00	10.00	12.50	5.00		5.00
H3777	001	2	1	01	01	H3777_001_2	9			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3777	001	2	1	01	01	H3777_001_2	9			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	99.00	198.00	297.00																									99.00	198.00	297.00				99.00	198.00	247.50				99.00				99.00		3.30				3.30	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3777	001	2	1	01	01	H3777_001_2	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3777	001	2	1	01	01	H3777_001_2	9			Select Care Drugs	4	11	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3777	001	2	1	01	01	H3777_001_2	9			Select Care Drugs	4	11	1	2	6	3	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3777	001	3	1	01	01	H3777_001_3	9			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H3777	001	3	1	01	01	H3777_001_3	9			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	5.00	10.00	15.00																									5.00	10.00	15.00				5.00	10.00	12.50				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00	5.00	10.00	12.50	5.00		5.00
H3777	001	3	1	01	01	H3777_001_3	9			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3777	001	3	1	01	01	H3777_001_3	9			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	99.00	198.00	297.00																									99.00	198.00	297.00				99.00	198.00	247.50				99.00				99.00		3.30				3.30	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3777	001	3	1	01	01	H3777_001_3	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3777	001	3	1	01	01	H3777_001_3	9			Select Care Drugs	4	11	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3777	001	3	1	01	01	H3777_001_3	9			Select Care Drugs	4	11	1	2	6	3	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3777	001	4	1	01	01	H3777_001_4	9			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H3777	001	4	1	01	01	H3777_001_4	9			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	5.00	10.00	15.00																									5.00	10.00	15.00				5.00	10.00	12.50				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00	5.00	10.00	12.50	5.00		5.00
H3777	001	4	1	01	01	H3777_001_4	9			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	45.00	90.00	135.00																									45.00	90.00	135.00				45.00	90.00	112.50				45.00				45.00		1.50				1.50	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3777	001	4	1	01	01	H3777_001_4	9			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	99.00	198.00	297.00																									99.00	198.00	297.00				99.00	198.00	247.50				99.00				99.00		3.30				3.30	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3777	001	4	1	01	01	H3777_001_4	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3777	001	4	1	01	01	H3777_001_4	9			Select Care Drugs	4	11	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3777	001	4	1	01	01	H3777_001_4	9			Select Care Drugs	4	11	1	2	6	3	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3805	001	0	1	02	01	H3805_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	001	0	1	02	01	H3805_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	001	0	1	02	01	H3805_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	001	0	1	02	01	H3805_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	001	0	1	02	01	H3805_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	001	0	1	02	01	H3805_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	001	0	1	02	01	H3805_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				581.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	015	0	1	02	01	H3805_015_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	015	0	1	02	01	H3805_015_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	015	0	1	02	01	H3805_015_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	015	0	1	02	01	H3805_015_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	015	0	1	02	01	H3805_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	015	0	1	02	01	H3805_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	015	0	1	02	01	H3805_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				518.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	017	0	1	02	01	H3805_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	017	0	1	02	01	H3805_017_0	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	017	0	1	02	01	H3805_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	017	0	1	02	01	H3805_017_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	017	0	1	02	01	H3805_017_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	017	0	1	02	01	H3805_017_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	017	0	1	02	01	H3805_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				663.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	032	0	1	02	01	H3805_032_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	032	0	1	02	01	H3805_032_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	032	0	1	02	01	H3805_032_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	032	0	1	02	01	H3805_032_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	032	0	1	02	01	H3805_032_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	032	0	1	02	01	H3805_032_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	032	0	1	02	01	H3805_032_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				409.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	033	0	1	02	01	H3805_033_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	033	0	1	02	01	H3805_033_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	033	0	1	02	01	H3805_033_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	033	0	1	02	01	H3805_033_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	033	0	1	02	01	H3805_033_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	033	0	1	02	01	H3805_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	033	0	1	02	01	H3805_033_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				447.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	034	0	1	02	01	H3805_034_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	034	0	1	02	01	H3805_034_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	034	0	1	02	01	H3805_034_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	034	0	1	02	01	H3805_034_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	034	0	1	02	01	H3805_034_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	034	0	1	02	01	H3805_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	034	0	1	02	01	H3805_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				599.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	037	0	1	02	01	H3805_037_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	037	0	1	02	01	H3805_037_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	037	0	1	02	01	H3805_037_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	037	0	1	02	01	H3805_037_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	037	0	1	02	01	H3805_037_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	037	0	1	02	01	H3805_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	037	0	1	02	01	H3805_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				541.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	039	1	1	02	01	H3805_039_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	039	1	1	02	01	H3805_039_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	039	1	1	02	01	H3805_039_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	039	1	1	02	01	H3805_039_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	039	1	1	02	01	H3805_039_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	039	1	1	02	01	H3805_039_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	039	1	1	02	01	H3805_039_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				487.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	039	2	1	02	01	H3805_039_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	039	2	1	02	01	H3805_039_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3805	039	2	1	02	01	H3805_039_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3805	039	2	1	02	01	H3805_039_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H3805	039	2	1	02	01	H3805_039_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	039	2	1	02	01	H3805_039_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H3805	039	2	1	02	01	H3805_039_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				487.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3810	003	0	1	01	01	H3810_003_0	11			Preferred Generic	4	01	3	2	1	1	111		01		100	1	30	60	100				1	2						100	30		31	5.00	10.00	0.00																											15.00						0.00				5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													5.00	10.00	0.00						15.00			0.00	5.00		5.00
H3810	003	0	1	01	01	H3810_003_0	11			Preferred Generic	4	01	3	2	1	3	111		01		100	1	30	60	100				1	2						100	30		31	10.00	20.00	0.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H3810	003	0	1	01	01	H3810_003_0	11			Generic	4	01	1	2	2	1	111		01		100	1	30	60	100				1	2						100	30		31	15.00	30.00	30.00																											45.00						30.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	003	0	1	01	01	H3810_003_0	11			Preferred Brand	4	10	1	2	3	1	111		01		100	1	30	60	100				1	2						100	30		31	47.00	94.00	94.00																											141.00						94.00				47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00			70.00	35.00		35.00
H3810	003	0	1	01	01	H3810_003_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		01		100	1	30	60	100				1	2						100	30		31	98.00	196.00	196.00																											294.00						196.00				98.00				98.00		3.27						3.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	003	0	1	01	01	H3810_003_0	11			Specialty Tier	4	11	1	1	5	1	111		01		100	1	30	60	100				1	2						100	30		31					30	30	30																										30						30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	003	0	1	01	01	H3810_003_0	11			Select Care Drugs	4	11	1	2	6	1	111		01		100	1	30	60	100				1	2						100	30		31	0.00	0.00	0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	003	0	1	01	01	H3810_003_0	11			Select Care Drugs	4	11	1	2	6	3	111		01		100	1	30	60	100				1	2						100	30		31	0.00	0.00	0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H3810	022	0	1	01	01	H3810_022_0	8			Preferred Generic	4	01	3	2	1	1	111		01		100	1	30	60	100				1	2						100	30		31	5.00	10.00	0.00																											15.00						0.00				5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													5.00	10.00	0.00						15.00			0.00	5.00		5.00
H3810	022	0	1	01	01	H3810_022_0	8			Preferred Generic	4	01	3	2	1	3	111		01		100	1	30	60	100				1	2						100	30		31	10.00	20.00	0.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H3810	022	0	1	01	01	H3810_022_0	8			Generic	4	01	1	2	2	1	111		01		100	1	30	60	100				1	2						100	30		31	15.00	30.00	45.00																											45.00						45.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	022	0	1	01	01	H3810_022_0	8			Preferred Brand	4	10	1	2	3	1	111		01		100	1	30	60	100				1	2						100	30		31	47.00	94.00	141.00																											141.00						141.00				47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00			105.00	35.00		35.00
H3810	022	0	1	01	01	H3810_022_0	8			Non-Preferred Brand	4	10	1	2	4	1	111		01		100	1	30	60	100				1	2						100	30		31	100.00	200.00	300.00																											300.00						300.00				100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	022	0	1	01	01	H3810_022_0	8			Specialty Tier	4	11	1	1	5	1	111		01		100	1	30	60	100				1	2						100	30		31				0.00	28	28	28																										28						28			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	022	0	1	01	01	H3810_022_0	8			Select Care Drugs	4	11	1	2	6	1	111		01		100	1	30	60	100				1	2						100	30		31	0.00	0.00	0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H3810	022	0	1	01	01	H3810_022_0	8			Select Care Drugs	4	11	1	2	6	3	111		01		100	1	30	60	100				1	2						100	30		31	0.00	0.00	0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H3811	002	0	1	01	01	H3811_002_0	8			Preferred Generic	4	11	1	2	1	1	110		01	100		1	34		90				1	2			90				34		31	3.00		6.00																					6.00																3.00				3.00		0.09						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00		6.00						6.00				3.00		3.00
H3811	002	0	1	01	01	H3811_002_0	8			Generic	4	11	1	2	2	1	110		01	100		1	34		90				1	2			90				34		31	9.00		18.00																					18.00																9.00				9.00		0.26						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00		18.00						18.00				9.00		9.00
H3811	002	0	1	01	01	H3811_002_0	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	34		90				1	2			90				34		31	47.00		94.00																					94.00																47.00				47.00		1.38						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		94.00						94.00				35.00		35.00
H3811	002	0	1	01	01	H3811_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	34		90				1	2			90				34		31	100.00		200.00																					200.00																100.00				100.00		2.94						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3811	002	0	1	01	01	H3811_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	34														34		31				1278.15	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3811	002	0	1	01	01	H3811_002_0	8			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	34		100				1	2			100				34		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3811	002	0	1	01	01	H3811_002_0	8			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	34		100				1	2			100				34		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3811	009	0	1	01	01	H3811_009_0	8			Preferred Generic	4	11	1	2	1	1	110		01	100		1	34		90				1	2			90				34		31	3.00		6.00																					6.00																3.00				3.00		0.09						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00		6.00						6.00				3.00		3.00
H3811	009	0	1	01	01	H3811_009_0	8			Preferred Generic	4	11	1	2	1	3	110		01	100		1	34		90				1	2			90				34		31	3.00		6.00																					6.00																3.00				3.00		0.09						0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3811	009	0	1	01	01	H3811_009_0	8			Generic	4	11	1	2	2	1	110		01	100		1	34		90				1	2			90				34		31	9.00		18.00																					18.00																9.00				9.00		0.26						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00		18.00						18.00				9.00		9.00
H3811	009	0	1	01	01	H3811_009_0	8			Generic	4	11	1	2	2	3	110		01	100		1	34		90				1	2			90				34		31	9.00		18.00																					18.00																9.00				9.00		0.26						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3811	009	0	1	01	01	H3811_009_0	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	34		90				1	2			90				34		31	47.00		94.00																					94.00																47.00				47.00		1.38						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		94.00						94.00				35.00		35.00
H3811	009	0	1	01	01	H3811_009_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	34		90				1	2			90				34		31	100.00		200.00																					200.00																100.00				100.00		2.94						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3811	009	0	1	01	01	H3811_009_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	34														34		31				1489.50	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3811	009	0	1	01	01	H3811_009_0	8			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	34		100				1	2			100				34		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3811	009	0	1	01	01	H3811_009_0	8			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	34		100				1	2			100				34		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3813	010	0	1	04	01	H3813_010_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	17.50					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.00	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00		7.00
H3813	010	0	1	04	01	H3813_010_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								14.00	28.00	35.00					7.00	14.00	17.50											7.00	14.00	17.50				7.00	14.00	17.50				14.00				14.00			0.47	0.23		0.23	0.23	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50	7.00	14.00	17.50	14.00		14.00
H3813	010	0	1	04	01	H3813_010_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	117.50					40.00	80.00	100.00											40.00	80.00	100.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.33	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00
H3813	010	0	1	04	01	H3813_010_0	6			Non-Preferred Brand	4	10	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	250.00					93.00	186.00	232.50											100.00	200.00	250.00				93.00	186.00	232.50				100.00				100.00			3.33	3.10		3.33	3.10	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3813	010	0	1	04	01	H3813_010_0	6			Preferred Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								31			30		31											250.00	25						230.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	010	0	1	04	01	H3813_010_0	6			Specialty Tier	4	11	1	1	6	1		010	01		010	1				30								30			30		31											280.00	30						250.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	010	0	1	04	01	H3813_010_0	6			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01		000	1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	012	0	1	04	01	H3813_012_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	012	0	1	04	01	H3813_012_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	012	0	1	04	01	H3813_012_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	012	0	1	04	01	H3813_012_0	7			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	012	0	1	04	01	H3813_012_0	7			Preferred Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											250.00	25						230.00	25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	012	0	1	04	01	H3813_012_0	7			Specialty Tier	4	11	1	1	6	1		010	01	000		1				30											30		31											280.00	30						250.00	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	012	0	1	04	01	H3813_012_0	7			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	013	0	1	04	01	H3813_013_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	013	0	1	04	01	H3813_013_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	013	0	1	04	01	H3813_013_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	013	0	1	04	01	H3813_013_0	8			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	013	0	1	04	01	H3813_013_0	8			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											250.00	25						230.00	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	013	0	1	04	01	H3813_013_0	8			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	30						250.00	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	013	0	1	04	01	H3813_013_0	8			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	014	0	1	04	01	H3813_014_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	014	0	1	04	01	H3813_014_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	014	0	1	04	01	H3813_014_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	014	0	1	04	01	H3813_014_0	7			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	014	0	1	04	01	H3813_014_0	7			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											250.00	25						230.00	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	014	0	1	04	01	H3813_014_0	7			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	30						250.00	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	014	0	1	04	01	H3813_014_0	7			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	016	0	1	04	01	H3813_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	016	0	1	04	01	H3813_016_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	016	0	1	04	01	H3813_016_0	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	016	0	1	04	01	H3813_016_0	6			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	016	0	1	04	01	H3813_016_0	6			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											250.00	24						230.00	24						24																	24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	016	0	1	04	01	H3813_016_0	6			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	29						250.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	016	0	1	04	01	H3813_016_0	6			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	017	0	1	04	01	H3813_017_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	017	0	1	04	01	H3813_017_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	017	0	1	04	01	H3813_017_0	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	017	0	1	04	01	H3813_017_0	6			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	017	0	1	04	01	H3813_017_0	6			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											250.00	24						230.00	24						24																	24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	017	0	1	04	01	H3813_017_0	6			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	29						250.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	017	0	1	04	01	H3813_017_0	6			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	018	0	1	04	01	H3813_018_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	018	0	1	04	01	H3813_018_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	018	0	1	04	01	H3813_018_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	018	0	1	04	01	H3813_018_0	7			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	018	0	1	04	01	H3813_018_0	7			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											250.00	24						230.00	24						24																	24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	018	0	1	04	01	H3813_018_0	7			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	29						250.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	018	0	1	04	01	H3813_018_0	7			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	019	0	1	04	01	H3813_019_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	17.50					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													7.00	14.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00				7.00		7.00
H3813	019	0	1	04	01	H3813_019_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	35.00					7.00	14.00	17.50					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	35.00	7.00	14.00	17.50	7.00	14.00	17.50				14.00		14.00
H3813	019	0	1	04	01	H3813_019_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3813	019	0	1	04	01	H3813_019_0	7			Non-Preferred Brand	4	10	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	250.00					93.00	186.00	232.50					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3813	019	0	1	04	01	H3813_019_0	7			Preferred Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											250.00	24						230.00	24						24																	24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	019	0	1	04	01	H3813_019_0	7			Specialty Tier	4	11	1	1	6	1		010	01	010		1				30					30						30		31											280.00	29						250.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3813	019	0	1	04	01	H3813_019_0	7			Vaccines ($0 cost sharing)	4	11	1	2	7	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Vaccines ($0 cost sharing)																											
H3814	031	0	1	01	01	H3814_031_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	5.00		10.00																					10.00																5.00				5.00		0.16						0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3814	031	0	1	01	01	H3814_031_0	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	20.00		40.00																					40.00																20.00				20.00		0.65						0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3814	031	0	1	01	01	H3814_031_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H3814	031	0	1	01	01	H3814_031_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3814	031	0	1	01	01	H3814_031_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				1152.15	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3814	031	0	1	01	01	H3814_031_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H3815	001	0	1	01	01	H3815_001_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	001	0	1	01	01	H3815_001_0	16			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	001	0	1	01	01	H3815_001_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H3815	001	0	1	01	01	H3815_001_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	75.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00				30.00	60.00	75.00				30.00		30.00
H3815	001	0	1	01	01	H3815_001_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	001	0	1	01	01	H3815_001_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				745.30	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	001	0	1	01	01	H3815_001_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	001	0	1	01	01	H3815_001_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	007	0	1	01	01	H3815_007_0	19			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	007	0	1	01	01	H3815_007_0	19			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H3815	007	0	1	01	01	H3815_007_0	19			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	007	0	1	01	01	H3815_007_0	19			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	007	0	1	01	01	H3815_007_0	19			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				699.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	007	0	1	01	01	H3815_007_0	19			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	007	0	1	01	01	H3815_007_0	19			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	008	0	1	01	01	H3815_008_0	19			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	008	0	1	01	01	H3815_008_0	19			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	008	0	1	01	01	H3815_008_0	19			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	008	0	1	01	01	H3815_008_0	19			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	008	0	1	01	01	H3815_008_0	19			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	75.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00				30.00	60.00	75.00				30.00		30.00
H3815	008	0	1	01	01	H3815_008_0	19			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	75.00	150.00	225.00																			75.00	150.00	187.50																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	008	0	1	01	01	H3815_008_0	19			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				604.71	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	008	0	1	01	01	H3815_008_0	19			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	008	0	1	01	01	H3815_008_0	19			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	010	0	1	01	01	H3815_010_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	010	0	1	01	01	H3815_010_0	16			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	010	0	1	01	01	H3815_010_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H3815	010	0	1	01	01	H3815_010_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	75.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00				30.00	60.00	75.00				30.00		30.00
H3815	010	0	1	01	01	H3815_010_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	75.00	150.00	225.00																			75.00	150.00	187.50																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	010	0	1	01	01	H3815_010_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				773.50	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	010	0	1	01	01	H3815_010_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	010	0	1	01	01	H3815_010_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	011	0	1	01	01	H3815_011_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	011	0	1	01	01	H3815_011_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00				10.00	20.00	25.00				10.00		10.00
H3815	011	0	1	01	01	H3815_011_0	14			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	100.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	100.00				35.00		35.00
H3815	011	0	1	01	01	H3815_011_0	14			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	93.00	186.00	279.00																			93.00	186.00	232.50																93.00				93.00		3.10			3.10			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	011	0	1	01	01	H3815_011_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				550.04	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	011	0	1	01	01	H3815_011_0	14			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	011	0	1	01	01	H3815_011_0	14			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	013	0	1	01	01	H3815_013_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	013	0	1	01	01	H3815_013_0	15			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	013	0	1	01	01	H3815_013_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	013	0	1	01	01	H3815_013_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	75.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00				30.00	60.00	75.00				30.00		30.00
H3815	013	0	1	01	01	H3815_013_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	013	0	1	01	01	H3815_013_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				931.13	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	013	0	1	01	01	H3815_013_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	013	0	1	01	01	H3815_013_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	016	0	1	02	01	H3815_016_0	17			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	016	0	1	02	01	H3815_016_0	17			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	016	0	1	02	01	H3815_016_0	17			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H3815	016	0	1	02	01	H3815_016_0	17			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	90.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00				30.00	60.00	90.00				30.00		30.00
H3815	016	0	1	02	01	H3815_016_0	17			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	75.00	150.00	225.00																			75.00	150.00	225.00																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	016	0	1	02	01	H3815_016_0	17			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				764.88	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	016	0	1	02	01	H3815_016_0	17			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	016	0	1	02	01	H3815_016_0	17			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	019	0	1	01	01	H3815_019_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	019	0	1	01	01	H3815_019_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H3815	019	0	1	01	01	H3815_019_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	019	0	1	01	01	H3815_019_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	019	0	1	01	01	H3815_019_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				762.70	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	019	0	1	01	01	H3815_019_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	019	0	1	01	01	H3815_019_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	020	0	1	01	01	H3815_020_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	020	0	1	01	01	H3815_020_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H3815	020	0	1	01	01	H3815_020_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	020	0	1	01	01	H3815_020_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	020	0	1	01	01	H3815_020_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				704.64	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	020	0	1	01	01	H3815_020_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	020	0	1	01	01	H3815_020_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	021	0	1	01	01	H3815_021_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	021	0	1	01	01	H3815_021_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H3815	021	0	1	01	01	H3815_021_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	021	0	1	01	01	H3815_021_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	021	0	1	01	01	H3815_021_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				939.75	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	021	0	1	01	01	H3815_021_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	021	0	1	01	01	H3815_021_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	023	0	1	01	01	H3815_023_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	023	0	1	01	01	H3815_023_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H3815	023	0	1	01	01	H3815_023_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	023	0	1	01	01	H3815_023_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	023	0	1	01	01	H3815_023_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				612.20	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	023	0	1	01	01	H3815_023_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	023	0	1	01	01	H3815_023_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	026	0	1	02	01	H3815_026_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	026	0	1	02	01	H3815_026_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H3815	026	0	1	02	01	H3815_026_0	14			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	026	0	1	02	01	H3815_026_0	14			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	93.00	186.00	279.00																			93.00	186.00	279.00																93.00				93.00		3.10			3.10			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	026	0	1	02	01	H3815_026_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				498.45	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	026	0	1	02	01	H3815_026_0	14			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	026	0	1	02	01	H3815_026_0	14			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	028	0	1	01	01	H3815_028_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	028	0	1	01	01	H3815_028_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H3815	028	0	1	01	01	H3815_028_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	028	0	1	01	01	H3815_028_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	93.00	186.00	279.00																			93.00	186.00	279.00																93.00				93.00		3.10			3.10			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	028	0	1	01	01	H3815_028_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				844.68	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	028	0	1	01	01	H3815_028_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	028	0	1	01	01	H3815_028_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	031	0	1	01	01	H3815_031_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	031	0	1	01	01	H3815_031_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H3815	031	0	1	01	01	H3815_031_0	14			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	031	0	1	01	01	H3815_031_0	14			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	93.00	186.00	279.00																			93.00	186.00	279.00																93.00				93.00		3.10			3.10			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	031	0	1	01	01	H3815_031_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				583.88	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	031	0	1	01	01	H3815_031_0	14			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	031	0	1	01	01	H3815_031_0	14			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	033	0	1	01	01	H3815_033_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	033	0	1	01	01	H3815_033_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	033	0	1	01	01	H3815_033_0	11			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	033	0	1	01	01	H3815_033_0	11			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	033	0	1	01	01	H3815_033_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				414.57	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	033	0	1	01	01	H3815_033_0	11			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	033	0	1	01	01	H3815_033_0	11			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	034	0	1	01	01	H3815_034_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	034	0	1	01	01	H3815_034_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	1.00	2.00	3.00																			1.00	2.00	3.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													1.00	2.00	3.00				1.00	2.00	3.00				1.00		1.00
H3815	034	0	1	01	01	H3815_034_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	034	0	1	01	01	H3815_034_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	034	0	1	01	01	H3815_034_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				598.43	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	034	0	1	01	01	H3815_034_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	034	0	1	01	01	H3815_034_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	035	0	1	01	01	H3815_035_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	035	0	1	01	01	H3815_035_0	16			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	035	0	1	01	01	H3815_035_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	035	0	1	01	01	H3815_035_0	16			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	035	0	1	01	01	H3815_035_0	16			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	035	0	1	01	01	H3815_035_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				696.82	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	035	0	1	01	01	H3815_035_0	16			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	035	0	1	01	01	H3815_035_0	16			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	036	0	1	01	01	H3815_036_0	17			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	036	0	1	01	01	H3815_036_0	17			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H3815	036	0	1	01	01	H3815_036_0	17			Preferred Brand	4	11	3	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				76.66	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	036	0	1	01	01	H3815_036_0	17			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.46	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	036	0	1	01	01	H3815_036_0	17			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				521.42	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	036	0	1	01	01	H3815_036_0	17			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	037	0	1	01	01	H3815_037_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	037	0	1	01	01	H3815_037_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H3815	037	0	1	01	01	H3815_037_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	037	0	1	01	01	H3815_037_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	93.00	186.00	279.00																			93.00	186.00	279.00																93.00				93.00		3.10			3.10			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	037	0	1	01	01	H3815_037_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				615.05	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	037	0	1	01	01	H3815_037_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	037	0	1	01	01	H3815_037_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	038	0	1	01	01	H3815_038_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	038	0	1	01	01	H3815_038_0	15			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	038	0	1	01	01	H3815_038_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	038	0	1	01	01	H3815_038_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	038	0	1	01	01	H3815_038_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	038	0	1	01	01	H3815_038_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				496.88	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	038	0	1	01	01	H3815_038_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	038	0	1	01	01	H3815_038_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	040	0	1	01	01	H3815_040_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	040	0	1	01	01	H3815_040_0	15			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3815	040	0	1	01	01	H3815_040_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3815	040	0	1	01	01	H3815_040_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	040	0	1	01	01	H3815_040_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3815	040	0	1	01	01	H3815_040_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				496.79	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	040	0	1	01	01	H3815_040_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3815	040	0	1	01	01	H3815_040_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3817	008	1	1	04	01	H3817_008_1	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	008	1	1	04	01	H3817_008_1	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H3817	008	1	1	04	01	H3817_008_1	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3817	008	1	1	04	01	H3817_008_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	008	1	1	04	01	H3817_008_1	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	008	2	1	04	01	H3817_008_2	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	008	2	1	04	01	H3817_008_2	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H3817	008	2	1	04	01	H3817_008_2	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3817	008	2	1	04	01	H3817_008_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	008	2	1	04	01	H3817_008_2	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	008	4	1	04	01	H3817_008_4	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	008	4	1	04	01	H3817_008_4	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H3817	008	4	1	04	01	H3817_008_4	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3817	008	4	1	04	01	H3817_008_4	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	008	4	1	04	01	H3817_008_4	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	009	1	1	04	01	H3817_009_1	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	009	1	1	04	01	H3817_009_1	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H3817	009	1	1	04	01	H3817_009_1	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3817	009	1	1	04	01	H3817_009_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	009	1	1	04	01	H3817_009_1	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1138.94	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	009	2	1	04	01	H3817_009_2	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	009	2	1	04	01	H3817_009_2	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H3817	009	2	1	04	01	H3817_009_2	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H3817	009	2	1	04	01	H3817_009_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	009	2	1	04	01	H3817_009_2	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1138.94	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	011	1	1	04	01	H3817_011_1	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	011	1	1	04	01	H3817_011_1	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H3817	011	1	1	04	01	H3817_011_1	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	011	1	1	04	01	H3817_011_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	011	1	1	04	01	H3817_011_1	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	011	2	1	04	01	H3817_011_2	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	011	2	1	04	01	H3817_011_2	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H3817	011	2	1	04	01	H3817_011_2	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	011	2	1	04	01	H3817_011_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	011	2	1	04	01	H3817_011_2	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3817	011	3	1	04	01	H3817_011_3	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3817	011	3	1	04	01	H3817_011_3	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H3817	011	3	1	04	01	H3817_011_3	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	011	3	1	04	01	H3817_011_3	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H3817	011	3	1	04	01	H3817_011_3	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3822	001	0	1	01	01	H3822_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3822	001	0	1	01	01	H3822_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3822	001	0	1	01	01	H3822_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3822	001	0	1	01	01	H3822_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3822	001	0	1	01	01	H3822_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3822	001	0	1	01	01	H3822_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3822	002	0	1	01	01	H3822_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3822	002	0	1	01	01	H3822_002_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3822	002	0	1	01	01	H3822_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3822	002	0	1	01	01	H3822_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3822	002	0	1	01	01	H3822_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3822	002	0	1	01	01	H3822_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3822	007	0	1	02	01	H3822_007_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3822	007	0	1	02	01	H3822_007_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3822	007	0	1	02	01	H3822_007_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3822	007	0	1	02	01	H3822_007_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3822	007	0	1	02	01	H3822_007_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3822	007	0	1	02	01	H3822_007_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3822	008	0	1	02	01	H3822_008_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3822	008	0	1	02	01	H3822_008_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3822	008	0	1	02	01	H3822_008_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3822	008	0	1	02	01	H3822_008_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3822	008	0	1	02	01	H3822_008_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3822	008	0	1	02	01	H3822_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3822	012	0	1	01	01	H3822_012_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3822	012	0	1	01	01	H3822_012_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3822	012	0	1	01	01	H3822_012_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3822	012	0	1	01	01	H3822_012_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3822	012	0	1	01	01	H3822_012_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3822	012	0	1	01	01	H3822_012_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3822	014	0	1	01	01	H3822_014_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3822	014	0	1	01	01	H3822_014_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3822	014	0	1	01	01	H3822_014_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3822	014	0	1	01	01	H3822_014_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3822	014	0	1	01	01	H3822_014_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3822	014	0	1	01	01	H3822_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3828	001	0	1	04	01	H3828_001_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H3828	001	0	1	04	01	H3828_001_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3828	001	0	1	04	01	H3828_001_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					0.00	0.00	0.00																20.00				20.00			0.67	0.33	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	0.00	0.00	0.00				20.00		20.00
H3828	001	0	1	04	01	H3828_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3828	001	0	1	04	01	H3828_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3828	001	0	1	04	01	H3828_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	30						950.00	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H3832	007	0	1	04	01	H3832_007_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	5.00	5.00				5.00		5.00
H3832	007	0	1	04	01	H3832_007_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	20.00	20.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	20.00	20.00				20.00		20.00
H3832	007	0	1	04	01	H3832_007_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	007	0	1	04	01	H3832_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	007	0	1	04	01	H3832_007_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					27	27	27																		27	27	27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3832	008	0	1	04	01	H3832_008_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	4.00	4.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00				4.00	4.00	4.00				4.00		4.00
H3832	008	0	1	04	01	H3832_008_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	4.00	4.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3832	008	0	1	04	01	H3832_008_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	11.00	11.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00				11.00	11.00	11.00				11.00		11.00
H3832	008	0	1	04	01	H3832_008_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	008	0	1	04	01	H3832_008_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	008	0	1	04	01	H3832_008_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3832	009	0	1	04	01	H3832_009_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.50	9.00	13.50																			4.50	4.50	4.50																4.50				4.50		0.15			0.15			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.50	9.00	13.50				4.50	4.50	4.50				4.50		4.50
H3832	009	0	1	04	01	H3832_009_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	12.00	12.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00				12.00	12.00	12.00				12.00		12.00
H3832	009	0	1	04	01	H3832_009_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	009	0	1	04	01	H3832_009_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	009	0	1	04	01	H3832_009_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					27	27	27																		27	27	27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3832	010	0	1	04	01	H3832_010_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	4.00	4.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00				4.00	4.00	4.00				4.00		4.00
H3832	010	0	1	04	01	H3832_010_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	4.00	4.00																4.00				4.00		0.13			0.13			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3832	010	0	1	04	01	H3832_010_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	11.00	11.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00				11.00	11.00	11.00				11.00		11.00
H3832	010	0	1	04	01	H3832_010_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	010	0	1	04	01	H3832_010_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H3832	010	0	1	04	01	H3832_010_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3864	006	0	1	01	01	H3864_006_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	006	0	1	01	01	H3864_006_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	006	0	1	01	01	H3864_006_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	006	0	1	01	01	H3864_006_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											60.24	33	33	33				57.16	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	006	0	1	01	01	H3864_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											135.79	33						122.97	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	006	0	1	01	01	H3864_006_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	006	0	1	01	01	H3864_006_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	014	0	1	02	01	H3864_014_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	014	0	1	02	01	H3864_014_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	014	0	1	02	01	H3864_014_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	014	0	1	02	01	H3864_014_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.39	33	33	33				58.60	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	014	0	1	02	01	H3864_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											161.01	33						137.07	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	014	0	1	02	01	H3864_014_0	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	014	0	1	02	01	H3864_014_0	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	024	0	1	02	01	H3864_024_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	024	0	1	02	01	H3864_024_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	024	0	1	02	01	H3864_024_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	024	0	1	02	01	H3864_024_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											70.61	31	31	31				60.96	30	30	30										31	31	31				30	30	30			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	024	0	1	02	01	H3864_024_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											198.84	31						233.22	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	024	0	1	02	01	H3864_024_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	024	0	1	02	01	H3864_024_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	027	0	1	01	01	H3864_027_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	027	0	1	01	01	H3864_027_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	027	0	1	01	01	H3864_027_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	027	0	1	01	01	H3864_027_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.49	32	32	32				76.23	31	31	31										32	32	32				31	31	31			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	027	0	1	01	01	H3864_027_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											210.22	27						206.03	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	027	0	1	01	01	H3864_027_0	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	027	0	1	01	01	H3864_027_0	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	029	0	1	02	01	H3864_029_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	029	0	1	02	01	H3864_029_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	029	0	1	02	01	H3864_029_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	029	0	1	02	01	H3864_029_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.78	33	33	33				56.70	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	029	0	1	02	01	H3864_029_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											207.57	30						178.86	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	029	0	1	02	01	H3864_029_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	029	0	1	02	01	H3864_029_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	032	0	1	02	01	H3864_032_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	032	0	1	02	01	H3864_032_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	032	0	1	02	01	H3864_032_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	032	0	1	02	01	H3864_032_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											60.46	33	33	33				55.04	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	032	0	1	02	01	H3864_032_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											163.80	33						156.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	032	0	1	02	01	H3864_032_0	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	032	0	1	02	01	H3864_032_0	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	034	0	1	02	01	H3864_034_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	034	0	1	02	01	H3864_034_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					0.00	0.00	0.00											17.00	34.00	51.00				0.00	0.00	0.00				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	034	0	1	02	01	H3864_034_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	034	0	1	02	01	H3864_034_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.01	33	33	33				51.97	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	034	0	1	02	01	H3864_034_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											149.00	33						136.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	034	0	1	02	01	H3864_034_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	034	0	1	02	01	H3864_034_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	036	0	1	02	01	H3864_036_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	036	0	1	02	01	H3864_036_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	036	0	1	02	01	H3864_036_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	036	0	1	02	01	H3864_036_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											78.30	33	33	33				71.27	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	036	0	1	02	01	H3864_036_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											175.05	30						155.60	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	036	0	1	02	01	H3864_036_0	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	036	0	1	02	01	H3864_036_0	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	040	0	1	01	01	H3864_040_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	040	0	1	01	01	H3864_040_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					9.00	18.00	27.00											17.00	34.00	51.00				9.00	18.00	18.00				17.00				17.00			0.57	0.30		0.57	0.30	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	040	0	1	01	01	H3864_040_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	040	0	1	01	01	H3864_040_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.99	33	33	33				51.66	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	040	0	1	01	01	H3864_040_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											163.16	33						146.83	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	040	0	1	01	01	H3864_040_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	040	0	1	01	01	H3864_040_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	041	0	1	01	01	H3864_041_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	041	0	1	01	01	H3864_041_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	041	0	1	01	01	H3864_041_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H3864	041	0	1	01	01	H3864_041_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.21	33	33	33				51.05	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	041	0	1	01	01	H3864_041_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											144.48	33						133.56	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3864	041	0	1	01	01	H3864_041_0	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	041	0	1	01	01	H3864_041_0	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3864	043	0	1	01	01	H3864_043_0	5		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	043	0	1	01	01	H3864_043_0	5		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	043	0	1	01	01	H3864_043_0	5		N	Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H3864	043	0	1	01	01	H3864_043_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				80.88	34	34	34																		34	34	34															34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	043	0	1	01	01	H3864_043_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				146.76	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H3864	043	0	1	01	01	H3864_043_0	5		N	Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3864	043	0	1	01	01	H3864_043_0	5		N	Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H3890	001	0	1	04	01	H3890_001_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	6.00	8.00																			4.00	6.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	6.00	8.00				4.00	6.00	8.00				4.00		4.00
H3890	001	0	1	04	01	H3890_001_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	18.00	24.00																			12.00	18.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	18.00	24.00				12.00	18.00	24.00				12.00		12.00
H3890	001	0	1	04	01	H3890_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	70.50	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	001	0	1	04	01	H3890_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	150.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	001	0	1	04	01	H3890_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3890	002	0	1	04	01	H3890_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	6.00	8.00																			4.00	6.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	6.00	8.00				4.00	6.00	8.00				4.00		4.00
H3890	002	0	1	04	01	H3890_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	18.00	24.00																			12.00	18.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	18.00	24.00				12.00	18.00	24.00				12.00		12.00
H3890	002	0	1	04	01	H3890_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	70.50	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	002	0	1	04	01	H3890_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	150.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	002	0	1	04	01	H3890_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3890	004	0	1	04	01	H3890_004_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H3890	004	0	1	04	01	H3890_004_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	15.00	20.00																			10.00	15.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	15.00	20.00				10.00	15.00	20.00				10.00		10.00
H3890	004	0	1	04	01	H3890_004_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	40.00	80.00	120.00																			40.00	60.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	004	0	1	04	01	H3890_004_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	90.00	180.00	270.00																			90.00	135.00	180.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	004	0	1	04	01	H3890_004_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3890	005	0	1	04	01	H3890_005_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	7.50	10.00																			5.00	7.50	10.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	7.50	10.00				5.00	7.50	10.00				5.00		5.00
H3890	005	0	1	04	01	H3890_005_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	30.00	40.00																			20.00	30.00	40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	30.00	40.00				20.00	30.00	40.00				20.00		20.00
H3890	005	0	1	04	01	H3890_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	70.50	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	005	0	1	04	01	H3890_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	150.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	52.50	70.00				35.00		35.00
H3890	005	0	1	04	01	H3890_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H3907	006	0	1	01	01	H3907_006_0	11			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	006	0	1	01	01	H3907_006_0	11			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	006	0	1	01	01	H3907_006_0	11			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	006	0	1	01	01	H3907_006_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	006	0	1	01	01	H3907_006_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											972.69	33						1258.32	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	029	0	1	01	01	H3907_029_0	11			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	029	0	1	01	01	H3907_029_0	11			Preferred Generic	4	11	1	2	1	3		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H3907	029	0	1	01	01	H3907_029_0	11			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	029	0	1	01	01	H3907_029_0	11			Generic	4	11	1	2	2	3		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H3907	029	0	1	01	01	H3907_029_0	11			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	029	0	1	01	01	H3907_029_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	029	0	1	01	01	H3907_029_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1130.48	33						1305.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	037	0	1	01	01	H3907_037_0	8			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	037	0	1	01	01	H3907_037_0	8			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	037	0	1	01	01	H3907_037_0	8			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	037	0	1	01	01	H3907_037_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	037	0	1	01	01	H3907_037_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1260.73	33						1408.03	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	046	0	1	01	01	H3907_046_0	10			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	046	0	1	01	01	H3907_046_0	10			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	046	0	1	01	01	H3907_046_0	10			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	046	0	1	01	01	H3907_046_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	046	0	1	01	01	H3907_046_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1055.98	33						1224.93	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	050	0	1	01	01	H3907_050_0	9			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	050	0	1	01	01	H3907_050_0	9			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	050	0	1	01	01	H3907_050_0	9			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	050	0	1	01	01	H3907_050_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	050	0	1	01	01	H3907_050_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1052.60	33						1192.18	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	052	0	1	01	01	H3907_052_0	11			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	052	0	1	01	01	H3907_052_0	11			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	052	0	1	01	01	H3907_052_0	11			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	052	0	1	01	01	H3907_052_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	052	0	1	01	01	H3907_052_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1270.17	33						1351.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	1	1	01	01	H3907_057_1	12			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	1	1	01	01	H3907_057_1	12			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	1	1	01	01	H3907_057_1	12			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	057	1	1	01	01	H3907_057_1	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	1	1	01	01	H3907_057_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1220.85	33						1440.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	2	1	01	01	H3907_057_2	12			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	2	1	01	01	H3907_057_2	12			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	2	1	01	01	H3907_057_2	12			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	057	2	1	01	01	H3907_057_2	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	2	1	01	01	H3907_057_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1220.85	33						1440.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	3	1	01	01	H3907_057_3	12			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	3	1	01	01	H3907_057_3	12			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	3	1	01	01	H3907_057_3	12			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	057	3	1	01	01	H3907_057_3	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	3	1	01	01	H3907_057_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1220.85	33						1440.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	4	1	01	01	H3907_057_4	12			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	4	1	01	01	H3907_057_4	12			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	4	1	01	01	H3907_057_4	12			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	057	4	1	01	01	H3907_057_4	12			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	4	1	01	01	H3907_057_4	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1220.85	33						1440.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	5	1	01	01	H3907_057_5	13			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	5	1	01	01	H3907_057_5	13			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	5	1	01	01	H3907_057_5	13			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H3907	057	5	1	01	01	H3907_057_5	13			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3907	057	5	1	01	01	H3907_057_5	13			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1220.85	33						1440.88	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	001	0	1	04	01	H3909_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	001	0	1	04	01	H3909_001_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	14.00					7.00	14.00	14.00																20.00				20.00			0.67	0.23	0.23			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	001	0	1	04	01	H3909_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	001	0	1	04	01	H3909_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	001	0	1	04	01	H3909_001_0	6			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	009	0	1	04	01	H3909_009_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	009	0	1	04	01	H3909_009_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	14.00					7.00	14.00	14.00																20.00				20.00			0.67	0.23	0.23			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	009	0	1	04	01	H3909_009_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	009	0	1	04	01	H3909_009_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	009	0	1	04	01	H3909_009_0	6			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	014	0	1	04	01	H3909_014_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	014	0	1	04	01	H3909_014_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	014	0	1	04	01	H3909_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	014	0	1	04	01	H3909_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	014	0	1	04	01	H3909_014_0	7			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	015	0	1	04	01	H3909_015_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	015	0	1	04	01	H3909_015_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	015	0	1	04	01	H3909_015_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	015	0	1	04	01	H3909_015_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	015	0	1	04	01	H3909_015_0	7			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	016	0	1	04	01	H3909_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	016	0	1	04	01	H3909_016_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	016	0	1	04	01	H3909_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	016	0	1	04	01	H3909_016_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	016	0	1	04	01	H3909_016_0	6			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	017	0	1	04	01	H3909_017_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	017	0	1	04	01	H3909_017_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3909	017	0	1	04	01	H3909_017_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	017	0	1	04	01	H3909_017_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3909	017	0	1	04	01	H3909_017_0	6			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3916	001	0	1	04	01	H3916_001_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	001	0	1	04	01	H3916_001_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3916	001	0	1	04	01	H3916_001_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	001	0	1	04	01	H3916_001_0	7			Generic	4	01	1	2	2	3		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3916	001	0	1	04	01	H3916_001_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H3916	001	0	1	04	01	H3916_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H3916	001	0	1	04	01	H3916_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1548.86	33						1548.86	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	002	0	1	04	01	H3916_002_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	002	0	1	04	01	H3916_002_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3916	002	0	1	04	01	H3916_002_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	002	0	1	04	01	H3916_002_0	7			Generic	4	01	1	2	2	3		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3916	002	0	1	04	01	H3916_002_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	002	0	1	04	01	H3916_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	002	0	1	04	01	H3916_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1417.63	33						1417.63	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	005	0	1	04	01	H3916_005_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	005	0	1	04	01	H3916_005_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3916	005	0	1	04	01	H3916_005_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	005	0	1	04	01	H3916_005_0	7			Generic	4	01	1	2	2	3		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3916	005	0	1	04	01	H3916_005_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H3916	005	0	1	04	01	H3916_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H3916	005	0	1	04	01	H3916_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1403.03	33						1403.03	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	015	0	1	04	01	H3916_015_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	015	0	1	04	01	H3916_015_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	015	0	1	04	01	H3916_015_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	015	0	1	04	01	H3916_015_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	015	0	1	04	01	H3916_015_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1214.83	33						1214.83	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	018	0	1	04	01	H3916_018_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	018	0	1	04	01	H3916_018_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	018	0	1	04	01	H3916_018_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	018	0	1	04	01	H3916_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H3916	018	0	1	04	01	H3916_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1337.64	33						1337.64	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	022	0	1	04	01	H3916_022_0	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	022	0	1	04	01	H3916_022_0	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	022	0	1	04	01	H3916_022_0	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	022	0	1	04	01	H3916_022_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	022	0	1	04	01	H3916_022_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1283.90	33						1283.90	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	024	0	1	04	01	H3916_024_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	024	0	1	04	01	H3916_024_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	024	0	1	04	01	H3916_024_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	024	0	1	04	01	H3916_024_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	024	0	1	04	01	H3916_024_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1088.89	33						1088.89	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	032	0	1	04	01	H3916_032_0	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	032	0	1	04	01	H3916_032_0	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	032	0	1	04	01	H3916_032_0	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	032	0	1	04	01	H3916_032_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	032	0	1	04	01	H3916_032_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1087.72	33						1087.72	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	033	0	1	04	01	H3916_033_0	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	033	0	1	04	01	H3916_033_0	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	033	0	1	04	01	H3916_033_0	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	033	0	1	04	01	H3916_033_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	033	0	1	04	01	H3916_033_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1388.67	33						1388.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	1	1	04	01	H3916_034_1	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	1	1	04	01	H3916_034_1	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	1	1	04	01	H3916_034_1	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	1	1	04	01	H3916_034_1	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	1	1	04	01	H3916_034_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1171.59	33						1171.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	3	1	04	01	H3916_034_3	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	3	1	04	01	H3916_034_3	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	3	1	04	01	H3916_034_3	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	3	1	04	01	H3916_034_3	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	3	1	04	01	H3916_034_3	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1171.59	33						1171.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	4	1	04	01	H3916_034_4	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	4	1	04	01	H3916_034_4	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	4	1	04	01	H3916_034_4	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	4	1	04	01	H3916_034_4	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	4	1	04	01	H3916_034_4	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1171.59	33						1171.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	5	1	04	01	H3916_034_5	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	5	1	04	01	H3916_034_5	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	034	5	1	04	01	H3916_034_5	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	5	1	04	01	H3916_034_5	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	034	5	1	04	01	H3916_034_5	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1171.59	33						1171.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	1	1	04	01	H3916_035_1	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	1	1	04	01	H3916_035_1	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	1	1	04	01	H3916_035_1	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	035	1	1	04	01	H3916_035_1	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						280.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	035	1	1	04	01	H3916_035_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1258.71	33						1258.71	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	2	1	04	01	H3916_035_2	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	2	1	04	01	H3916_035_2	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	2	1	04	01	H3916_035_2	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	035	2	1	04	01	H3916_035_2	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						280.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	035	2	1	04	01	H3916_035_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1258.71	33						1258.71	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	4	1	04	01	H3916_035_4	9			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	4	1	04	01	H3916_035_4	9			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	035	4	1	04	01	H3916_035_4	9			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	035	4	1	04	01	H3916_035_4	9			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						280.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	035	4	1	04	01	H3916_035_4	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1258.71	33						1258.71	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	036	0	1	04	01	H3916_036_0	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	036	0	1	04	01	H3916_036_0	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	036	0	1	04	01	H3916_036_0	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	036	0	1	04	01	H3916_036_0	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	036	0	1	04	01	H3916_036_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1197.80	33						1197.80	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	1	1	04	01	H3916_037_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	1	1	04	01	H3916_037_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	1	1	04	01	H3916_037_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	1	1	04	01	H3916_037_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	1	1	04	01	H3916_037_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1148.67	33						1148.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	2	1	04	01	H3916_037_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	2	1	04	01	H3916_037_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	2	1	04	01	H3916_037_2	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	2	1	04	01	H3916_037_2	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	2	1	04	01	H3916_037_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1148.67	33						1148.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	3	1	04	01	H3916_037_3	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	3	1	04	01	H3916_037_3	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	3	1	04	01	H3916_037_3	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	3	1	04	01	H3916_037_3	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	3	1	04	01	H3916_037_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1148.67	33						1148.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	4	1	04	01	H3916_037_4	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	4	1	04	01	H3916_037_4	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	037	4	1	04	01	H3916_037_4	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	4	1	04	01	H3916_037_4	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	037	4	1	04	01	H3916_037_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1148.67	33						1148.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	038	0	1	04	01	H3916_038_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	038	0	1	04	01	H3916_038_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	038	0	1	04	01	H3916_038_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H3916	038	0	1	04	01	H3916_038_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	038	0	1	04	01	H3916_038_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1033.04	33						1033.04	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	039	0	1	04	01	H3916_039_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	039	0	1	04	01	H3916_039_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	039	0	1	04	01	H3916_039_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	039	0	1	04	01	H3916_039_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	039	0	1	04	01	H3916_039_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1424.84	33						1424.84	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	041	1	1	04	01	H3916_041_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	041	1	1	04	01	H3916_041_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	041	1	1	04	01	H3916_041_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	041	1	1	04	01	H3916_041_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	041	1	1	04	01	H3916_041_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1345.82	33						1345.82	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	041	2	1	04	01	H3916_041_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	041	2	1	04	01	H3916_041_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	041	2	1	04	01	H3916_041_2	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	041	2	1	04	01	H3916_041_2	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	041	2	1	04	01	H3916_041_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1345.82	33						1345.82	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	1	1	04	01	H3916_044_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	1	1	04	01	H3916_044_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	1	1	04	01	H3916_044_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	044	1	1	04	01	H3916_044_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						280.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	044	1	1	04	01	H3916_044_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	2	1	04	01	H3916_044_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	2	1	04	01	H3916_044_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	2	1	04	01	H3916_044_2	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	044	2	1	04	01	H3916_044_2	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						280.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	044	2	1	04	01	H3916_044_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	3	1	04	01	H3916_044_3	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	3	1	04	01	H3916_044_3	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.65	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	044	3	1	04	01	H3916_044_3	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	044	3	1	04	01	H3916_044_3	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						280.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	044	3	1	04	01	H3916_044_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	1	1	04	01	H3916_045_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	1	1	04	01	H3916_045_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	1	1	04	01	H3916_045_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	1	1	04	01	H3916_045_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	1	1	04	01	H3916_045_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	2	1	04	01	H3916_045_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	2	1	04	01	H3916_045_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	2	1	04	01	H3916_045_2	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	2	1	04	01	H3916_045_2	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	2	1	04	01	H3916_045_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	3	1	04	01	H3916_045_3	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	3	1	04	01	H3916_045_3	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	3	1	04	01	H3916_045_3	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	3	1	04	01	H3916_045_3	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	3	1	04	01	H3916_045_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	4	1	04	01	H3916_045_4	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	4	1	04	01	H3916_045_4	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	045	4	1	04	01	H3916_045_4	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	4	1	04	01	H3916_045_4	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	045	4	1	04	01	H3916_045_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	046	0	1	04	01	H3916_046_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	046	0	1	04	01	H3916_046_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3916	046	0	1	04	01	H3916_046_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	046	0	1	04	01	H3916_046_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3916	046	0	1	04	01	H3916_046_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1183.01	33						1183.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3923	013	0	1	04	01	H3923_013_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3923	013	0	1	04	01	H3923_013_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	15.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	15.00	20.00		20.00
H3923	013	0	1	04	01	H3923_013_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	013	0	1	04	01	H3923_013_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	013	0	1	04	01	H3923_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	017	0	1	04	01	H3923_017_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	8.00	16.00	24.00	0.00	0.00	0.00	8.00		8.00
H3923	017	0	1	04	01	H3923_017_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	15.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	15.00	20.00		20.00
H3923	017	0	1	04	01	H3923_017_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	017	0	1	04	01	H3923_017_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	017	0	1	04	01	H3923_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	028	0	1	04	01	H3923_028_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	12.00	24.00	36.00	0.00	0.00	0.00	12.00		12.00
H3923	028	0	1	04	01	H3923_028_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	15.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	15.00	20.00		20.00
H3923	028	0	1	04	01	H3923_028_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	028	0	1	04	01	H3923_028_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	028	0	1	04	01	H3923_028_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	029	0	1	04	01	H3923_029_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	12.00	24.00	36.00	0.00	0.00	0.00	12.00		12.00
H3923	029	0	1	04	01	H3923_029_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H3923	029	0	1	04	01	H3923_029_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	029	0	1	04	01	H3923_029_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	029	0	1	04	01	H3923_029_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	030	0	1	04	01	H3923_030_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3923	030	0	1	04	01	H3923_030_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3923	030	0	1	04	01	H3923_030_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	030	0	1	04	01	H3923_030_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	030	0	1	04	01	H3923_030_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	031	0	1	04	01	H3923_031_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	12.00	24.00	36.00	0.00	0.00	0.00	12.00		12.00
H3923	031	0	1	04	01	H3923_031_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	36.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	36.00	20.00		20.00
H3923	031	0	1	04	01	H3923_031_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	031	0	1	04	01	H3923_031_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	031	0	1	04	01	H3923_031_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	032	0	1	04	01	H3923_032_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	12.00	24.00	36.00	0.00	0.00	0.00	12.00		12.00
H3923	032	0	1	04	01	H3923_032_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	36.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	36.00	20.00		20.00
H3923	032	0	1	04	01	H3923_032_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	032	0	1	04	01	H3923_032_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	032	0	1	04	01	H3923_032_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	033	0	1	04	01	H3923_033_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	12.00	24.00	36.00	0.00	0.00	0.00	12.00		12.00
H3923	033	0	1	04	01	H3923_033_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	36.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	36.00	20.00		20.00
H3923	033	0	1	04	01	H3923_033_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	033	0	1	04	01	H3923_033_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	033	0	1	04	01	H3923_033_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	034	0	1	04	01	H3923_034_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3923	034	0	1	04	01	H3923_034_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3923	034	0	1	04	01	H3923_034_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	034	0	1	04	01	H3923_034_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	034	0	1	04	01	H3923_034_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3923	035	0	1	04	01	H3923_035_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3923	035	0	1	04	01	H3923_035_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3923	035	0	1	04	01	H3923_035_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	035	0	1	04	01	H3923_035_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3923	035	0	1	04	01	H3923_035_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3924	059	21	1	04	01	H3924_059_21	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	21	1	04	01	H3924_059_21	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	059	21	1	04	01	H3924_059_21	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	21	1	04	01	H3924_059_21	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	059	21	1	04	01	H3924_059_21	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	059	21	1	04	01	H3924_059_21	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	21	1	04	01	H3924_059_21	5			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	21	1	04	01	H3924_059_21	5			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	059	22	1	04	01	H3924_059_22	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	22	1	04	01	H3924_059_22	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	059	22	1	04	01	H3924_059_22	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	22	1	04	01	H3924_059_22	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	059	22	1	04	01	H3924_059_22	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	059	22	1	04	01	H3924_059_22	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	22	1	04	01	H3924_059_22	5			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	059	22	1	04	01	H3924_059_22	5			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	21	1	04	01	H3924_062_21	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	21	1	04	01	H3924_062_21	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	21	1	04	01	H3924_062_21	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	12.50																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	21	1	04	01	H3924_062_21	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	21	1	04	01	H3924_062_21	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	21	1	04	01	H3924_062_21	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	21	1	04	01	H3924_062_21	4			Vaccines ($0 cost sharing)	4	01	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	21	1	04	01	H3924_062_21	4			Vaccines ($0 cost sharing)	4	01	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	22	1	04	01	H3924_062_22	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	22	1	04	01	H3924_062_22	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	22	1	04	01	H3924_062_22	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	12.50																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	22	1	04	01	H3924_062_22	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	22	1	04	01	H3924_062_22	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	22	1	04	01	H3924_062_22	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	22	1	04	01	H3924_062_22	4			Vaccines ($0 cost sharing)	4	01	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	22	1	04	01	H3924_062_22	4			Vaccines ($0 cost sharing)	4	01	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	23	1	04	01	H3924_062_23	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	23	1	04	01	H3924_062_23	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	23	1	04	01	H3924_062_23	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	12.50																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	23	1	04	01	H3924_062_23	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	23	1	04	01	H3924_062_23	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	23	1	04	01	H3924_062_23	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	23	1	04	01	H3924_062_23	4			Vaccines ($0 cost sharing)	4	01	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	23	1	04	01	H3924_062_23	4			Vaccines ($0 cost sharing)	4	01	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	24	1	04	01	H3924_062_24	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	24	1	04	01	H3924_062_24	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	24	1	04	01	H3924_062_24	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	12.50																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	24	1	04	01	H3924_062_24	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	24	1	04	01	H3924_062_24	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	24	1	04	01	H3924_062_24	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	24	1	04	01	H3924_062_24	4			Vaccines ($0 cost sharing)	4	01	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	24	1	04	01	H3924_062_24	4			Vaccines ($0 cost sharing)	4	01	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	25	1	04	01	H3924_062_25	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	25	1	04	01	H3924_062_25	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	062	25	1	04	01	H3924_062_25	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	12.50																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	25	1	04	01	H3924_062_25	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	25	1	04	01	H3924_062_25	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	062	25	1	04	01	H3924_062_25	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	25	1	04	01	H3924_062_25	4			Vaccines ($0 cost sharing)	4	01	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	062	25	1	04	01	H3924_062_25	4			Vaccines ($0 cost sharing)	4	01	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	065	0	1	04	01	H3924_065_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	065	0	1	04	01	H3924_065_0	5			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3924	065	0	1	04	01	H3924_065_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	065	0	1	04	01	H3924_065_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	065	0	1	04	01	H3924_065_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3924	065	0	1	04	01	H3924_065_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	065	0	1	04	01	H3924_065_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3924	065	0	1	04	01	H3924_065_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3928	001	0	1	01	01	H3928_001_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3928	001	0	1	01	01	H3928_001_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3928	001	0	1	01	01	H3928_001_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3928	001	0	1	01	01	H3928_001_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3928	001	0	1	01	01	H3928_001_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3928	001	0	1	01	01	H3928_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3928	001	0	1	01	01	H3928_001_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											757.24	33						611.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	004	0	1	02	01	H3931_004_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	004	0	1	02	01	H3931_004_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	004	0	1	02	01	H3931_004_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	004	0	1	02	01	H3931_004_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	004	0	1	02	01	H3931_004_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											97.51	25	25	25				86.80	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	004	0	1	02	01	H3931_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.07	50	50	50				52.21	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	004	0	1	02	01	H3931_004_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											789.36	29						464.18	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	064	0	1	02	01	H3931_064_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	064	0	1	02	01	H3931_064_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	064	0	1	02	01	H3931_064_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	064	0	1	02	01	H3931_064_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	064	0	1	02	01	H3931_064_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											97.85	25	25	25				89.17	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	064	0	1	02	01	H3931_064_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.94	50	50	50				55.11	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	064	0	1	02	01	H3931_064_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											982.95	29						685.64	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	070	0	1	02	01	H3931_070_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	070	0	1	02	01	H3931_070_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	070	0	1	02	01	H3931_070_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	070	0	1	02	01	H3931_070_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	070	0	1	02	01	H3931_070_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.11	25	25	25				96.30	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	070	0	1	02	01	H3931_070_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.35	50	50	50				49.46	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	070	0	1	02	01	H3931_070_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											722.14	29						573.76	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	091	0	1	02	01	H3931_091_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	091	0	1	02	01	H3931_091_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	091	0	1	02	01	H3931_091_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	091	0	1	02	01	H3931_091_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	091	0	1	02	01	H3931_091_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.88	25	25	25				69.81	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	091	0	1	02	01	H3931_091_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.88	40	40	40				70.45	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	091	0	1	02	01	H3931_091_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											684.34	29						518.05	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	092	0	1	02	01	H3931_092_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	092	0	1	02	01	H3931_092_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	092	0	1	02	01	H3931_092_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	092	0	1	02	01	H3931_092_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	092	0	1	02	01	H3931_092_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	092	0	1	02	01	H3931_092_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	092	0	1	02	01	H3931_092_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											787.56	33						591.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	094	0	1	02	01	H3931_094_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	094	0	1	02	01	H3931_094_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	094	0	1	02	01	H3931_094_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	094	0	1	02	01	H3931_094_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	094	0	1	02	01	H3931_094_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	094	0	1	02	01	H3931_094_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	094	0	1	02	01	H3931_094_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											802.12	33						654.82	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	095	0	1	02	01	H3931_095_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	095	0	1	02	01	H3931_095_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	095	0	1	02	01	H3931_095_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	095	0	1	02	01	H3931_095_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	095	0	1	02	01	H3931_095_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	095	0	1	02	01	H3931_095_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	095	0	1	02	01	H3931_095_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											740.38	33						650.01	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	096	0	1	02	01	H3931_096_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	096	0	1	02	01	H3931_096_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	096	0	1	02	01	H3931_096_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	096	0	1	02	01	H3931_096_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	096	0	1	02	01	H3931_096_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	096	0	1	02	01	H3931_096_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	096	0	1	02	01	H3931_096_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											790.73	28						624.38	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	097	0	1	02	01	H3931_097_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	097	0	1	02	01	H3931_097_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	097	0	1	02	01	H3931_097_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	097	0	1	02	01	H3931_097_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	097	0	1	02	01	H3931_097_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	097	0	1	02	01	H3931_097_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	097	0	1	02	01	H3931_097_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											868.09	28						594.67	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	098	0	1	02	01	H3931_098_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	098	0	1	02	01	H3931_098_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	098	0	1	02	01	H3931_098_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	098	0	1	02	01	H3931_098_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	098	0	1	02	01	H3931_098_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	098	0	1	02	01	H3931_098_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	098	0	1	02	01	H3931_098_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											911.52	33						685.73	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	099	0	1	02	01	H3931_099_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	099	0	1	02	01	H3931_099_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	099	0	1	02	01	H3931_099_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	099	0	1	02	01	H3931_099_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	099	0	1	02	01	H3931_099_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	099	0	1	02	01	H3931_099_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	099	0	1	02	01	H3931_099_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											880.78	33						812.49	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	100	0	1	02	01	H3931_100_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	100	0	1	02	01	H3931_100_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	100	0	1	02	01	H3931_100_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	100	0	1	02	01	H3931_100_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	100	0	1	02	01	H3931_100_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	100	0	1	02	01	H3931_100_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	100	0	1	02	01	H3931_100_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											831.24	33						678.63	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	101	0	1	02	01	H3931_101_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	101	0	1	02	01	H3931_101_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	101	0	1	02	01	H3931_101_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	101	0	1	02	01	H3931_101_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	101	0	1	02	01	H3931_101_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	101	0	1	02	01	H3931_101_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	101	0	1	02	01	H3931_101_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											907.00	33						788.25	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	102	0	1	02	01	H3931_102_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	102	0	1	02	01	H3931_102_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	102	0	1	02	01	H3931_102_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	102	0	1	02	01	H3931_102_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	102	0	1	02	01	H3931_102_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.06	25	25	25				47.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	102	0	1	02	01	H3931_102_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.65	50	50	50				57.65	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	102	0	1	02	01	H3931_102_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											869.22	33						687.43	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	105	0	1	02	01	H3931_105_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	105	0	1	02	01	H3931_105_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	105	0	1	02	01	H3931_105_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	105	0	1	02	01	H3931_105_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	105	0	1	02	01	H3931_105_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.33	25	25	25				94.48	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	105	0	1	02	01	H3931_105_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.94	50	50	50				55.42	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	105	0	1	02	01	H3931_105_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											805.81	29						585.01	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	107	0	1	02	01	H3931_107_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	107	0	1	02	01	H3931_107_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3931	107	0	1	02	01	H3931_107_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	107	0	1	02	01	H3931_107_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3931	107	0	1	02	01	H3931_107_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	107	0	1	02	01	H3931_107_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	107	0	1	02	01	H3931_107_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											974.14	33						629.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	108	0	1	01	01	H3931_108_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	108	0	1	01	01	H3931_108_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	108	0	1	01	01	H3931_108_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	108	0	1	01	01	H3931_108_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	108	0	1	01	01	H3931_108_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	108	0	1	01	01	H3931_108_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	108	0	1	01	01	H3931_108_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											949.60	33						715.01	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	109	0	1	02	01	H3931_109_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	109	0	1	02	01	H3931_109_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	109	0	1	02	01	H3931_109_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	109	0	1	02	01	H3931_109_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	109	0	1	02	01	H3931_109_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	109	0	1	02	01	H3931_109_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	109	0	1	02	01	H3931_109_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											713.85	28						553.27	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	124	0	1	02	01	H3931_124_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	124	0	1	02	01	H3931_124_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	124	0	1	02	01	H3931_124_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	124	0	1	02	01	H3931_124_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	124	0	1	02	01	H3931_124_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	124	0	1	02	01	H3931_124_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	124	0	1	02	01	H3931_124_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											688.29	28						596.17	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	126	0	1	02	01	H3931_126_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	126	0	1	02	01	H3931_126_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	126	0	1	02	01	H3931_126_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	126	0	1	02	01	H3931_126_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	126	0	1	02	01	H3931_126_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	126	0	1	02	01	H3931_126_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	126	0	1	02	01	H3931_126_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											672.04	30						531.60	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	129	0	1	02	01	H3931_129_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	129	0	1	02	01	H3931_129_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	129	0	1	02	01	H3931_129_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	129	0	1	02	01	H3931_129_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	129	0	1	02	01	H3931_129_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	129	0	1	02	01	H3931_129_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	129	0	1	02	01	H3931_129_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											791.44	33						621.40	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	143	0	1	02	01	H3931_143_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	143	0	1	02	01	H3931_143_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	143	0	1	02	01	H3931_143_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	143	0	1	02	01	H3931_143_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	143	0	1	02	01	H3931_143_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	143	0	1	02	01	H3931_143_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	143	0	1	02	01	H3931_143_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											769.73	30						747.46	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	145	0	1	02	01	H3931_145_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	145	0	1	02	01	H3931_145_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	145	0	1	02	01	H3931_145_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	145	0	1	02	01	H3931_145_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	145	0	1	02	01	H3931_145_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	145	0	1	02	01	H3931_145_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	145	0	1	02	01	H3931_145_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											871.15	33						632.39	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	146	0	1	02	01	H3931_146_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	146	0	1	02	01	H3931_146_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	146	0	1	02	01	H3931_146_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	146	0	1	02	01	H3931_146_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	146	0	1	02	01	H3931_146_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	146	0	1	02	01	H3931_146_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	146	0	1	02	01	H3931_146_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											866.03	33						626.63	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	147	0	1	02	01	H3931_147_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	147	0	1	02	01	H3931_147_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	147	0	1	02	01	H3931_147_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	147	0	1	02	01	H3931_147_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	147	0	1	02	01	H3931_147_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	147	0	1	02	01	H3931_147_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	147	0	1	02	01	H3931_147_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											877.25	33						630.99	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	148	0	1	02	01	H3931_148_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	148	0	1	02	01	H3931_148_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	148	0	1	02	01	H3931_148_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	148	0	1	02	01	H3931_148_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	148	0	1	02	01	H3931_148_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	148	0	1	02	01	H3931_148_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	148	0	1	02	01	H3931_148_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.27	28						542.67	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	149	0	1	02	01	H3931_149_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	149	0	1	02	01	H3931_149_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	149	0	1	02	01	H3931_149_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	149	0	1	02	01	H3931_149_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	149	0	1	02	01	H3931_149_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	149	0	1	02	01	H3931_149_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	149	0	1	02	01	H3931_149_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											823.65	30						567.80	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	151	0	1	02	01	H3931_151_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	151	0	1	02	01	H3931_151_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	151	0	1	02	01	H3931_151_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	151	0	1	02	01	H3931_151_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	151	0	1	02	01	H3931_151_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	151	0	1	02	01	H3931_151_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	151	0	1	02	01	H3931_151_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											879.00	33						632.78	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	152	0	1	02	01	H3931_152_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	152	0	1	02	01	H3931_152_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	152	0	1	02	01	H3931_152_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	152	0	1	02	01	H3931_152_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	152	0	1	02	01	H3931_152_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	152	0	1	02	01	H3931_152_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	152	0	1	02	01	H3931_152_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.16	33						608.95	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	153	0	1	02	01	H3931_153_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	153	0	1	02	01	H3931_153_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	153	0	1	02	01	H3931_153_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	153	0	1	02	01	H3931_153_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	153	0	1	02	01	H3931_153_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.37	25	25	25				47.43	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	153	0	1	02	01	H3931_153_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.79	50	50	50				60.27	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	153	0	1	02	01	H3931_153_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.33	33						611.97	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	154	0	1	02	01	H3931_154_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	154	0	1	02	01	H3931_154_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	154	0	1	02	01	H3931_154_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	154	0	1	02	01	H3931_154_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	154	0	1	02	01	H3931_154_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.40	25	25	25				47.49	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	154	0	1	02	01	H3931_154_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.62	50	50	50				60.39	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	154	0	1	02	01	H3931_154_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.20	33						614.23	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	156	0	1	02	01	H3931_156_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	156	0	1	02	01	H3931_156_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	156	0	1	02	01	H3931_156_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	156	0	1	02	01	H3931_156_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	156	0	1	02	01	H3931_156_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.94	25	25	25				95.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	156	0	1	02	01	H3931_156_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.73	40	40	40				43.32	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	156	0	1	02	01	H3931_156_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.85	27						576.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	157	0	1	02	01	H3931_157_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	157	0	1	02	01	H3931_157_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	157	0	1	02	01	H3931_157_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	157	0	1	02	01	H3931_157_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	157	0	1	02	01	H3931_157_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.41	25	25	25				94.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	157	0	1	02	01	H3931_157_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.95	40	40	40				41.05	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	157	0	1	02	01	H3931_157_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											638.01	27						580.20	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	158	0	1	02	01	H3931_158_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	158	0	1	02	01	H3931_158_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	158	0	1	02	01	H3931_158_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	158	0	1	02	01	H3931_158_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	158	0	1	02	01	H3931_158_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	158	0	1	02	01	H3931_158_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	158	0	1	02	01	H3931_158_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											805.04	33						696.19	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	160	0	1	02	01	H3931_160_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	160	0	1	02	01	H3931_160_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	160	0	1	02	01	H3931_160_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	160	0	1	02	01	H3931_160_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	160	0	1	02	01	H3931_160_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.41	25	25	25				94.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	160	0	1	02	01	H3931_160_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.95	40	40	40				41.05	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	160	0	1	02	01	H3931_160_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											638.01	27						580.20	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	161	0	1	02	01	H3931_161_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	161	0	1	02	01	H3931_161_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	161	0	1	02	01	H3931_161_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	161	0	1	02	01	H3931_161_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	161	0	1	02	01	H3931_161_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											108.35	25	25	25				96.26	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	161	0	1	02	01	H3931_161_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.28	50	50	50				52.13	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	161	0	1	02	01	H3931_161_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.54	29						613.83	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	162	0	1	02	01	H3931_162_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	162	0	1	02	01	H3931_162_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	162	0	1	02	01	H3931_162_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	162	0	1	02	01	H3931_162_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	162	0	1	02	01	H3931_162_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.10	25	25	25				98.79	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	162	0	1	02	01	H3931_162_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.33	50	50	50				47.81	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	162	0	1	02	01	H3931_162_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											824.89	29						604.89	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	165	0	1	02	01	H3931_165_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	165	0	1	02	01	H3931_165_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	165	0	1	02	01	H3931_165_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	165	0	1	02	01	H3931_165_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	165	0	1	02	01	H3931_165_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.19	25	25	25				95.71	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	165	0	1	02	01	H3931_165_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.95	40	40	40				41.48	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	165	0	1	02	01	H3931_165_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											640.79	27						583.19	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	166	0	1	02	01	H3931_166_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	166	0	1	02	01	H3931_166_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	166	0	1	02	01	H3931_166_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	166	0	1	02	01	H3931_166_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	166	0	1	02	01	H3931_166_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.94	25	25	25				95.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	166	0	1	02	01	H3931_166_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.73	40	40	40				43.32	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	166	0	1	02	01	H3931_166_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.85	27						576.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	167	0	1	02	01	H3931_167_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	167	0	1	02	01	H3931_167_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	167	0	1	02	01	H3931_167_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	167	0	1	02	01	H3931_167_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	167	0	1	02	01	H3931_167_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.94	25	25	25				95.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	167	0	1	02	01	H3931_167_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.73	40	40	40				43.32	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	167	0	1	02	01	H3931_167_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.85	27						576.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	168	0	1	02	01	H3931_168_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	168	0	1	02	01	H3931_168_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	168	0	1	02	01	H3931_168_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	168	0	1	02	01	H3931_168_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	168	0	1	02	01	H3931_168_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.94	25	25	25				95.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	168	0	1	02	01	H3931_168_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.73	40	40	40				43.32	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	168	0	1	02	01	H3931_168_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.85	27						576.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3931	169	0	1	02	01	H3931_169_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	169	0	1	02	01	H3931_169_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	169	0	1	02	01	H3931_169_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	169	0	1	02	01	H3931_169_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3931	169	0	1	02	01	H3931_169_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.94	25	25	25				95.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3931	169	0	1	02	01	H3931_169_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.73	40	40	40				43.32	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3931	169	0	1	02	01	H3931_169_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.85	27						576.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	024	0	1	01	01	H3949_024_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	024	0	1	01	01	H3949_024_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										2		2															
H3949	024	0	1	01	01	H3949_024_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	024	0	1	01	01	H3949_024_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	024	0	1	01	01	H3949_024_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	024	0	1	01	01	H3949_024_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											666.29	33						577.32	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3949	024	0	1	01	01	H3949_024_0	7			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					5.00	10.00	15.00											5.00	10.00	15.00				5.00	10.00	15.00				5.00				5.00			0.17	0.17		0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	15.00	5.00	10.00	15.00	5.00		5.00
H3949	030	0	1	01	01	H3949_030_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	030	0	1	01	01	H3949_030_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	030	0	1	01	01	H3949_030_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	030	0	1	01	01	H3949_030_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	030	0	1	01	01	H3949_030_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	030	0	1	01	01	H3949_030_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											670.17	33						510.73	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	031	0	1	01	01	H3949_031_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	031	0	1	01	01	H3949_031_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	031	0	1	01	01	H3949_031_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	031	0	1	01	01	H3949_031_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	031	0	1	01	01	H3949_031_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	031	0	1	01	01	H3949_031_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											695.09	33						587.45	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	032	0	1	01	01	H3949_032_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	032	0	1	01	01	H3949_032_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	032	0	1	01	01	H3949_032_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	032	0	1	01	01	H3949_032_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	032	0	1	01	01	H3949_032_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	032	0	1	01	01	H3949_032_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											602.82	33						583.93	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	034	0	1	01	01	H3949_034_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	034	0	1	01	01	H3949_034_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	034	0	1	01	01	H3949_034_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	034	0	1	01	01	H3949_034_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	034	0	1	01	01	H3949_034_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	034	0	1	01	01	H3949_034_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											560.27	33						450.54	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	035	0	1	01	01	H3949_035_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	035	0	1	01	01	H3949_035_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	035	0	1	01	01	H3949_035_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	035	0	1	01	01	H3949_035_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	035	0	1	01	01	H3949_035_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	035	0	1	01	01	H3949_035_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											673.59	33						500.05	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	045	0	1	01	01	H3949_045_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	045	0	1	01	01	H3949_045_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	045	0	1	01	01	H3949_045_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	045	0	1	01	01	H3949_045_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	045	0	1	01	01	H3949_045_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	045	0	1	01	01	H3949_045_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											690.42	33						525.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	046	0	1	01	01	H3949_046_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H3949	046	0	1	01	01	H3949_046_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	046	0	1	01	01	H3949_046_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H3949	046	0	1	01	01	H3949_046_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	046	0	1	01	01	H3949_046_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	046	0	1	01	01	H3949_046_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											681.83	33						523.71	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	047	0	1	01	01	H3949_047_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3949	047	0	1	01	01	H3949_047_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	047	0	1	01	01	H3949_047_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3949	047	0	1	01	01	H3949_047_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	047	0	1	01	01	H3949_047_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	047	0	1	01	01	H3949_047_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											692.13	33						525.49	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	048	0	1	01	01	H3949_048_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3949	048	0	1	01	01	H3949_048_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	048	0	1	01	01	H3949_048_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3949	048	0	1	01	01	H3949_048_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	048	0	1	01	01	H3949_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	048	0	1	01	01	H3949_048_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											692.24	33						525.79	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	049	0	1	01	01	H3949_049_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3949	049	0	1	01	01	H3949_049_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	049	0	1	01	01	H3949_049_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3949	049	0	1	01	01	H3949_049_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	049	0	1	01	01	H3949_049_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	049	0	1	01	01	H3949_049_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											692.35	33						524.15	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3949	050	0	1	01	01	H3949_050_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3949	050	0	1	01	01	H3949_050_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3949	050	0	1	01	01	H3949_050_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H3949	050	0	1	01	01	H3949_050_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	050	0	1	01	01	H3949_050_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3949	050	0	1	01	01	H3949_050_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.69	33						530.39	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3952	020	0	1	01	01	H3952_020_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	020	0	1	01	01	H3952_020_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	14.00					7.00	14.00	14.00																20.00				20.00			0.67	0.23	0.23			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	020	0	1	01	01	H3952_020_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	020	0	1	01	01	H3952_020_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	020	0	1	01	01	H3952_020_0	8			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	045	0	1	01	01	H3952_045_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	045	0	1	01	01	H3952_045_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	14.00					7.00	14.00	14.00																20.00				20.00			0.67	0.23	0.23			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	045	0	1	01	01	H3952_045_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	045	0	1	01	01	H3952_045_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	045	0	1	01	01	H3952_045_0	8			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	049	0	1	01	01	H3952_049_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	049	0	1	01	01	H3952_049_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	14.00					7.00	14.00	14.00																20.00				20.00			0.67	0.23	0.23			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	049	0	1	01	01	H3952_049_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	049	0	1	01	01	H3952_049_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	049	0	1	01	01	H3952_049_0	8			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											3.33	33	33	33				3.33	33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	051	0	1	01	01	H3952_051_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	051	0	1	01	01	H3952_051_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	14.00					7.00	14.00	14.00																20.00				20.00			0.67	0.23	0.23			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	051	0	1	01	01	H3952_051_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	051	0	1	01	01	H3952_051_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	051	0	1	01	01	H3952_051_0	8			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											3.33	33	33	33				3.33	33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	053	0	1	02	01	H3952_053_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	053	0	1	02	01	H3952_053_0	9			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	053	0	1	02	01	H3952_053_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	053	0	1	02	01	H3952_053_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	053	0	1	02	01	H3952_053_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	054	0	1	02	01	H3952_054_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	054	0	1	02	01	H3952_054_0	9			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	054	0	1	02	01	H3952_054_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	054	0	1	02	01	H3952_054_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	054	0	1	02	01	H3952_054_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	055	0	1	01	01	H3952_055_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	055	0	1	01	01	H3952_055_0	9			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	055	0	1	01	01	H3952_055_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	055	0	1	01	01	H3952_055_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	055	0	1	01	01	H3952_055_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	056	0	1	01	01	H3952_056_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	056	0	1	01	01	H3952_056_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3952	056	0	1	01	01	H3952_056_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	056	0	1	01	01	H3952_056_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3952	056	0	1	01	01	H3952_056_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H3954	157	21	1	01	01	H3954_157_21	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	21	1	01	01	H3954_157_21	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	157	21	1	01	01	H3954_157_21	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	21	1	01	01	H3954_157_21	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	157	21	1	01	01	H3954_157_21	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	157	21	1	01	01	H3954_157_21	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	21	1	01	01	H3954_157_21	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	21	1	01	01	H3954_157_21	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	157	22	1	01	01	H3954_157_22	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	22	1	01	01	H3954_157_22	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	157	22	1	01	01	H3954_157_22	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	22	1	01	01	H3954_157_22	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	157	22	1	01	01	H3954_157_22	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	157	22	1	01	01	H3954_157_22	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	22	1	01	01	H3954_157_22	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	22	1	01	01	H3954_157_22	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	157	23	1	01	01	H3954_157_23	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	23	1	01	01	H3954_157_23	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	157	23	1	01	01	H3954_157_23	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	23	1	01	01	H3954_157_23	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	157	23	1	01	01	H3954_157_23	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	157	23	1	01	01	H3954_157_23	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	23	1	01	01	H3954_157_23	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	157	23	1	01	01	H3954_157_23	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	158	13	1	01	01	H3954_158_13	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	13	1	01	01	H3954_158_13	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	158	13	1	01	01	H3954_158_13	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	13	1	01	01	H3954_158_13	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	158	13	1	01	01	H3954_158_13	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	158	13	1	01	01	H3954_158_13	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	13	1	01	01	H3954_158_13	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	13	1	01	01	H3954_158_13	4			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	158	14	1	01	01	H3954_158_14	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	14	1	01	01	H3954_158_14	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	158	14	1	01	01	H3954_158_14	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	14	1	01	01	H3954_158_14	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	158	14	1	01	01	H3954_158_14	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	158	14	1	01	01	H3954_158_14	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	14	1	01	01	H3954_158_14	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	158	14	1	01	01	H3954_158_14	4			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	160	0	1	01	01	H3954_160_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	160	0	1	01	01	H3954_160_0	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	160	0	1	01	01	H3954_160_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	160	0	1	01	01	H3954_160_0	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	160	0	1	01	01	H3954_160_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	160	0	1	01	01	H3954_160_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	160	0	1	01	01	H3954_160_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	160	0	1	01	01	H3954_160_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	161	0	1	01	01	H3954_161_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	161	0	1	01	01	H3954_161_0	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	3.00	6.00	7.50																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	161	0	1	01	01	H3954_161_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	20.00	40.00	50.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	161	0	1	01	01	H3954_161_0	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	161	0	1	01	01	H3954_161_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	87.50				35.00	52.50	52.50				35.00		35.00
H3954	161	0	1	01	01	H3954_161_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	161	0	1	01	01	H3954_161_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	161	0	1	01	01	H3954_161_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	163	0	1	01	01	H3954_163_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	163	0	1	01	01	H3954_163_0	4			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3954	163	0	1	01	01	H3954_163_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	12.50																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	163	0	1	01	01	H3954_163_0	4			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	117.50																			47.00	70.50	70.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													25.00	50.00	62.50				25.00	37.50	37.50				25.00		25.00
H3954	163	0	1	01	01	H3954_163_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	150.00	150.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													25.00	50.00	62.50				25.00	37.50	37.50				25.00		25.00
H3954	163	0	1	01	01	H3954_163_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	163	0	1	01	01	H3954_163_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H3954	163	0	1	01	01	H3954_163_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	3	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H3957	031	0	1	02	01	H3957_031_0	9			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	031	0	1	02	01	H3957_031_0	9			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	031	0	1	02	01	H3957_031_0	9			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	031	0	1	02	01	H3957_031_0	9			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	031	0	1	02	01	H3957_031_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1393.74	33						1393.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	039	0	1	01	01	H3957_039_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	039	0	1	01	01	H3957_039_0	7			Preferred Generic	4	01	1	2	1	3		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3957	039	0	1	01	01	H3957_039_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					0.00		0.00													57.00						0.00				19.00				19.00			0.61	0.00				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	039	0	1	01	01	H3957_039_0	7			Generic	4	01	1	2	2	3		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					0.00		0.00													57.00						0.00				19.00				19.00			0.61	0.00				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3957	039	0	1	01	01	H3957_039_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					40.00		120.00													141.00						92.50				47.00				47.00			1.52	1.29				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	20.00		60.00			60.00			60.00	20.00		20.00
H3957	039	0	1	01	01	H3957_039_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	039	0	1	01	01	H3957_039_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1298.15	33						1298.15	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	1	1	01	01	H3957_042_1	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	1	1	01	01	H3957_042_1	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	1	1	01	01	H3957_042_1	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	1	1	01	01	H3957_042_1	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	1	1	01	01	H3957_042_1	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1230.43	33						1230.43	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	2	1	01	01	H3957_042_2	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	2	1	01	01	H3957_042_2	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	2	1	01	01	H3957_042_2	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	2	1	01	01	H3957_042_2	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	2	1	01	01	H3957_042_2	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1230.43	33						1230.43	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	4	1	01	01	H3957_042_4	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	4	1	01	01	H3957_042_4	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	4	1	01	01	H3957_042_4	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	4	1	01	01	H3957_042_4	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	4	1	01	01	H3957_042_4	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1230.43	33						1230.43	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	5	1	01	01	H3957_042_5	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	5	1	01	01	H3957_042_5	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	042	5	1	01	01	H3957_042_5	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	5	1	01	01	H3957_042_5	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	042	5	1	01	01	H3957_042_5	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1230.43	33						1230.43	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	044	1	1	02	01	H3957_044_1	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	044	1	1	02	01	H3957_044_1	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	044	1	1	02	01	H3957_044_1	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	044	1	1	02	01	H3957_044_1	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	044	1	1	02	01	H3957_044_1	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1358.65	33						1358.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	044	4	1	02	01	H3957_044_4	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	044	4	1	02	01	H3957_044_4	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					13.00		39.00													57.00						27.00				19.00				19.00			0.61	0.42				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	044	4	1	02	01	H3957_044_4	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	044	4	1	02	01	H3957_044_4	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					95.00		285.00													300.00						275.00				100.00				100.00			3.23	3.06				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	044	4	1	02	01	H3957_044_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1358.65	33						1358.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	045	1	1	02	01	H3957_045_1	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	045	1	1	02	01	H3957_045_1	8			Generic	4	01	1	2	2	1	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	045	1	1	02	01	H3957_045_1	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	44.00		132.00																					110.00																44.00				44.00		1.42						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	045	1	1	02	01	H3957_045_1	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					250.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	045	1	1	02	01	H3957_045_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1535.68	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	045	2	1	02	01	H3957_045_2	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	045	2	1	02	01	H3957_045_2	8			Generic	4	01	1	2	2	1	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	045	2	1	02	01	H3957_045_2	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	44.00		132.00																					110.00																44.00				44.00		1.42						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	045	2	1	02	01	H3957_045_2	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					250.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	045	2	1	02	01	H3957_045_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1535.68	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	046	1	1	02	01	H3957_046_1	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	046	1	1	02	01	H3957_046_1	8			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3957	046	1	1	02	01	H3957_046_1	8			Generic	4	01	1	2	2	1	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	046	1	1	02	01	H3957_046_1	8			Generic	4	01	1	2	2	3	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3957	046	1	1	02	01	H3957_046_1	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	42.00		126.00																					105.00																42.00				42.00		1.35						1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	046	1	1	02	01	H3957_046_1	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					250.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	046	1	1	02	01	H3957_046_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1521.67	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	046	2	1	02	01	H3957_046_2	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	046	2	1	02	01	H3957_046_2	8			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3957	046	2	1	02	01	H3957_046_2	8			Generic	4	01	1	2	2	1	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	046	2	1	02	01	H3957_046_2	8			Generic	4	01	1	2	2	3	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3957	046	2	1	02	01	H3957_046_2	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	42.00		126.00																					105.00																42.00				42.00		1.35						1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	046	2	1	02	01	H3957_046_2	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					250.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H3957	046	2	1	02	01	H3957_046_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1521.67	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	1	1	01	01	H3957_047_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	1	1	01	01	H3957_047_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	1	1	01	01	H3957_047_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	047	1	1	01	01	H3957_047_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	047	1	1	01	01	H3957_047_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1378.95	33						1378.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	2	1	01	01	H3957_047_2	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	2	1	01	01	H3957_047_2	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	2	1	01	01	H3957_047_2	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	047	2	1	01	01	H3957_047_2	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	047	2	1	01	01	H3957_047_2	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1378.95	33						1378.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	3	1	01	01	H3957_047_3	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	3	1	01	01	H3957_047_3	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	047	3	1	01	01	H3957_047_3	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	047	3	1	01	01	H3957_047_3	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	047	3	1	01	01	H3957_047_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1378.95	33						1378.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	048	0	1	01	01	H3957_048_0	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	048	0	1	01	01	H3957_048_0	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3957	048	0	1	01	01	H3957_048_0	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	048	0	1	01	01	H3957_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H3957	048	0	1	01	01	H3957_048_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1340.42	33						1340.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	001	0	1	02	01	H3959_001_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	001	0	1	02	01	H3959_001_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	001	0	1	02	01	H3959_001_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	001	0	1	02	01	H3959_001_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	001	0	1	02	01	H3959_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	001	0	1	02	01	H3959_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	001	0	1	02	01	H3959_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1091.17	33						614.04	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	002	0	1	02	01	H3959_002_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	002	0	1	02	01	H3959_002_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	002	0	1	02	01	H3959_002_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	002	0	1	02	01	H3959_002_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	002	0	1	02	01	H3959_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	002	0	1	02	01	H3959_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	002	0	1	02	01	H3959_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1070.90	33						623.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	010	0	1	02	01	H3959_010_0	6			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	010	0	1	02	01	H3959_010_0	6			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	010	0	1	02	01	H3959_010_0	6			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	010	0	1	02	01	H3959_010_0	6			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	010	0	1	02	01	H3959_010_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	010	0	1	02	01	H3959_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	010	0	1	02	01	H3959_010_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											934.15	33						677.56	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	011	0	1	02	01	H3959_011_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	011	0	1	02	01	H3959_011_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	011	0	1	02	01	H3959_011_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	011	0	1	02	01	H3959_011_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	011	0	1	02	01	H3959_011_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	011	0	1	02	01	H3959_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	011	0	1	02	01	H3959_011_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.06	33						754.85	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	032	0	1	02	01	H3959_032_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	032	0	1	02	01	H3959_032_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	032	0	1	02	01	H3959_032_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	032	0	1	02	01	H3959_032_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H3959	032	0	1	02	01	H3959_032_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	032	0	1	02	01	H3959_032_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	032	0	1	02	01	H3959_032_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											944.46	33						593.02	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	033	0	1	02	01	H3959_033_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	033	0	1	02	01	H3959_033_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	033	0	1	02	01	H3959_033_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	033	0	1	02	01	H3959_033_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	033	0	1	02	01	H3959_033_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.72	25	25	25				45.99	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	033	0	1	02	01	H3959_033_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.65	50	50	50				71.75	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	033	0	1	02	01	H3959_033_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											773.07	33						696.45	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	037	0	1	02	01	H3959_037_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	037	0	1	02	01	H3959_037_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	037	0	1	02	01	H3959_037_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	037	0	1	02	01	H3959_037_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	037	0	1	02	01	H3959_037_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	037	0	1	02	01	H3959_037_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	037	0	1	02	01	H3959_037_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											788.32	33						662.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	039	0	1	02	01	H3959_039_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	039	0	1	02	01	H3959_039_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	039	0	1	02	01	H3959_039_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	039	0	1	02	01	H3959_039_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	039	0	1	02	01	H3959_039_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.31	25	25	25				47.42	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	039	0	1	02	01	H3959_039_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.08	50	50	50				67.83	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	039	0	1	02	01	H3959_039_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											664.85	33						574.09	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	045	0	1	02	01	H3959_045_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	045	0	1	02	01	H3959_045_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	045	0	1	02	01	H3959_045_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	045	0	1	02	01	H3959_045_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	045	0	1	02	01	H3959_045_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	045	0	1	02	01	H3959_045_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	045	0	1	02	01	H3959_045_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											736.27	30						607.85	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	046	0	1	02	01	H3959_046_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	046	0	1	02	01	H3959_046_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	046	0	1	02	01	H3959_046_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	046	0	1	02	01	H3959_046_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	046	0	1	02	01	H3959_046_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	046	0	1	02	01	H3959_046_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	046	0	1	02	01	H3959_046_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											791.54	30						578.10	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	047	0	1	02	01	H3959_047_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	047	0	1	02	01	H3959_047_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	047	0	1	02	01	H3959_047_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	047	0	1	02	01	H3959_047_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	047	0	1	02	01	H3959_047_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	047	0	1	02	01	H3959_047_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	047	0	1	02	01	H3959_047_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											804.79	30						606.31	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	049	0	1	02	01	H3959_049_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	049	0	1	02	01	H3959_049_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	049	0	1	02	01	H3959_049_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	049	0	1	02	01	H3959_049_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	049	0	1	02	01	H3959_049_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	049	0	1	02	01	H3959_049_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	049	0	1	02	01	H3959_049_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											769.99	30						611.40	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	051	0	1	02	01	H3959_051_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	051	0	1	02	01	H3959_051_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	051	0	1	02	01	H3959_051_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	051	0	1	02	01	H3959_051_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	051	0	1	02	01	H3959_051_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	051	0	1	02	01	H3959_051_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	051	0	1	02	01	H3959_051_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.80	30						603.09	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	052	0	1	02	01	H3959_052_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	052	0	1	02	01	H3959_052_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	052	0	1	02	01	H3959_052_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	052	0	1	02	01	H3959_052_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	052	0	1	02	01	H3959_052_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.05	25	25	25				51.72	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	052	0	1	02	01	H3959_052_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.07	50	50	50				66.81	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	052	0	1	02	01	H3959_052_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1058.03	33						685.08	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	053	0	1	02	01	H3959_053_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	053	0	1	02	01	H3959_053_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	053	0	1	02	01	H3959_053_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	053	0	1	02	01	H3959_053_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	053	0	1	02	01	H3959_053_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	053	0	1	02	01	H3959_053_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	053	0	1	02	01	H3959_053_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											722.60	33						614.22	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	055	0	1	02	01	H3959_055_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	055	0	1	02	01	H3959_055_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	055	0	1	02	01	H3959_055_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	055	0	1	02	01	H3959_055_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3959	055	0	1	02	01	H3959_055_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.00	25	25	25				48.45	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	055	0	1	02	01	H3959_055_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.30	50	50	50				65.76	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	055	0	1	02	01	H3959_055_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											894.96	33						724.09	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3959	068	0	1	02	01	H3959_068_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	068	0	1	02	01	H3959_068_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	068	0	1	02	01	H3959_068_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.07	25	25	25				119.04	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3959	068	0	1	02	01	H3959_068_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.03	40	40	40				43.42	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H3959	068	0	1	02	01	H3959_068_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.78	28						514.21	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3962	001	0	1	01	01	H3962_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	10.50	14.00					0.00	0.00	0.00											7.00	10.50	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	10.50	14.00	0.00	0.00	0.00	7.00	10.50	14.00	0.00	0.00	0.00	7.00		7.00
H3962	001	0	1	01	01	H3962_001_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	12.00	16.00					0.00	0.00	0.00											8.00	12.00	16.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	12.00	16.00	0.00	0.00	0.00	8.00	12.00	16.00	0.00	0.00	0.00	8.00		8.00
H3962	001	0	1	01	01	H3962_001_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	001	0	1	01	01	H3962_001_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	001	0	1	01	01	H3962_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3962	004	0	1	01	01	H3962_004_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	0.00	0.00	0.00	7.00	14.00	21.00	0.00	0.00	0.00	7.00		7.00
H3962	004	0	1	01	01	H3962_004_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	5.00	10.00	15.00	15.00	30.00	45.00	5.00	10.00	15.00	15.00		15.00
H3962	004	0	1	01	01	H3962_004_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	004	0	1	01	01	H3962_004_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	004	0	1	01	01	H3962_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3962	007	0	1	01	01	H3962_007_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3962	007	0	1	01	01	H3962_007_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
H3962	007	0	1	01	01	H3962_007_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	007	0	1	01	01	H3962_007_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	007	0	1	01	01	H3962_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3962	021	0	1	01	01	H3962_021_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H3962	021	0	1	01	01	H3962_021_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	5.00	10.00	15.00	15.00	30.00	45.00	5.00	10.00	15.00	15.00		15.00
H3962	021	0	1	01	01	H3962_021_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	021	0	1	01	01	H3962_021_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3962	021	0	1	01	01	H3962_021_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H3975	001	0	1	04	01	H3975_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								4.00	8.00	12.00					1.00	2.00	3.00											4.00	8.00	12.00				1.00	2.00	0.00				4.00				4.00			0.13	0.03		0.13	0.03	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3975	001	0	1	04	01	H3975_001_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								4.00	8.00	12.00					1.00	2.00	3.00											4.00	8.00	12.00				1.00	2.00	0.00				4.00				4.00			0.13	0.03		0.13	0.03	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H3975	001	0	1	04	01	H3975_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	0.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3975	001	0	1	04	01	H3975_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H3975	001	0	1	04	01	H3975_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											62.40	50	50	50				62.40	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3975	001	0	1	04	01	H3975_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H3975	001	0	1	04	01	H3975_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H3975	001	0	1	04	01	H3975_001_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H3979	001	0	1	01	01	H3979_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H3979	001	0	1	01	01	H3979_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H3979	001	0	1	01	01	H3979_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H3979	001	0	1	01	01	H3979_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H3979	001	0	1	01	01	H3979_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H3979	001	0	1	01	01	H3979_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4003	009	0	1	01	01	H4003_009_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	009	0	1	01	01	H4003_009_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4003	009	0	1	01	01	H4003_009_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	009	0	1	01	01	H4003_009_0	7			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4003	009	0	1	01	01	H4003_009_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	009	0	1	01	01	H4003_009_0	7			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	20.00		40.00																					40.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00		20.00						20.00				10.00		10.00
H4003	009	0	1	01	01	H4003_009_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				546.61	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4003	009	0	1	01	01	H4003_009_0	7			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4003	009	0	1	01	01	H4003_009_0	7			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4003	019	0	1	02	01	H4003_019_0	5			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	019	0	1	02	01	H4003_019_0	5			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4003	019	0	1	02	01	H4003_019_0	5			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	019	0	1	02	01	H4003_019_0	5			Generic	4	01	3	2	2	3	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2		1															
H4003	019	0	1	02	01	H4003_019_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	3.00		6.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	019	0	1	02	01	H4003_019_0	5			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													5.00		10.00						10.00				5.00		5.00
H4003	019	0	1	02	01	H4003_019_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				537.89	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4003	019	0	1	02	01	H4003_019_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4003	019	0	1	02	01	H4003_019_0	5			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4003	034	0	1	02	01	H4003_034_0	6			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	034	0	1	02	01	H4003_034_0	6			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4003	034	0	1	02	01	H4003_034_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	034	0	1	02	01	H4003_034_0	6			Generic	4	01	3	2	2	3	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2		1															
H4003	034	0	1	02	01	H4003_034_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	3.00		6.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	034	0	1	02	01	H4003_034_0	6			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													5.00		10.00						10.00				5.00		5.00
H4003	034	0	1	02	01	H4003_034_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				315.30	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4003	034	0	1	02	01	H4003_034_0	6			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4003	034	0	1	02	01	H4003_034_0	6			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4003	054	0	1	02	01	H4003_054_0	5			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	1.00		2.00																					2.00																1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	054	0	1	02	01	H4003_054_0	5			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	1.00		2.00																					2.00																1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4003	054	0	1	02	01	H4003_054_0	5			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	2.00		4.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	054	0	1	02	01	H4003_054_0	5			Generic	4	01	3	2	2	3	110		01	100		1	30		90				2	1			90				30		31	2.00		4.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2		1															
H4003	054	0	1	02	01	H4003_054_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	7.00		14.00																					14.00																7.00				7.00		0.23						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	054	0	1	02	01	H4003_054_0	5			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00		20.00						20.00				10.00		10.00
H4003	054	0	1	02	01	H4003_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				461.84	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4003	054	0	1	02	01	H4003_054_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4003	054	0	1	02	01	H4003_054_0	5			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4003	055	0	1	02	01	H4003_055_0	6			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	3.00		6.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	055	0	1	02	01	H4003_055_0	6			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	3.00		6.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4003	055	0	1	02	01	H4003_055_0	6			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	1			90				30		31	4.00		8.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	055	0	1	02	01	H4003_055_0	6			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	1			90				30		31	4.00		8.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4003	055	0	1	02	01	H4003_055_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4003	055	0	1	02	01	H4003_055_0	6			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	15.00		30.00																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													15.00		30.00						30.00				15.00		15.00
H4003	055	0	1	02	01	H4003_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				437.71	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4003	055	0	1	02	01	H4003_055_0	6			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4003	055	0	1	02	01	H4003_055_0	6			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4004	056	0	1	02	01	H4004_056_0	5			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	1.00		2.00																					2.00																1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	056	0	1	02	01	H4004_056_0	5			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	1.00		2.00																					2.00																1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4004	056	0	1	02	01	H4004_056_0	5			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	2.00		4.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	056	0	1	02	01	H4004_056_0	5			Generic	4	01	3	2	2	3	110		01	100		1	30		90				2	1			90				30		31	2.00		4.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2		1															
H4004	056	0	1	02	01	H4004_056_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	7.00		14.00																					14.00																7.00				7.00		0.23						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	056	0	1	02	01	H4004_056_0	5			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00		20.00						20.00				10.00		10.00
H4004	056	0	1	02	01	H4004_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				612.71	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4004	056	0	1	02	01	H4004_056_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4004	056	0	1	02	01	H4004_056_0	5			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4004	063	0	1	02	01	H4004_063_0	5			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	1.00		2.00																					2.00																1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	063	0	1	02	01	H4004_063_0	5			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	1.00		2.00																					2.00																1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4004	063	0	1	02	01	H4004_063_0	5			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	1			90				30		31	2.00		4.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	063	0	1	02	01	H4004_063_0	5			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	1			90				30		31	2.00		4.00																					4.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4004	063	0	1	02	01	H4004_063_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	063	0	1	02	01	H4004_063_0	5			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	15.00		30.00																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													15.00		30.00						30.00				15.00		15.00
H4004	063	0	1	02	01	H4004_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				569.73	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4004	063	0	1	02	01	H4004_063_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4004	063	0	1	02	01	H4004_063_0	5			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4004	065	0	1	02	01	H4004_065_0	5			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	065	0	1	02	01	H4004_065_0	5			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4004	065	0	1	02	01	H4004_065_0	5			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	065	0	1	02	01	H4004_065_0	5			Generic	4	01	3	2	2	3	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2		1															
H4004	065	0	1	02	01	H4004_065_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	065	0	1	02	01	H4004_065_0	5			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	7.00		14.00																					14.00																7.00				7.00		0.23						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													7.00		14.00						14.00				7.00		7.00
H4004	065	0	1	02	01	H4004_065_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				524.64	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4004	065	0	1	02	01	H4004_065_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4004	065	0	1	02	01	H4004_065_0	5			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4004	066	0	1	02	01	H4004_066_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				1	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	066	0	1	02	01	H4004_066_0	4			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		90				1	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4004	066	0	1	02	01	H4004_066_0	4			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	1			90				30		31	6.00		12.00																					12.00																6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	066	0	1	02	01	H4004_066_0	4			Generic	4	01	1	2	2	3	110		01	100		1	30		90				2	1			90				30		31	6.00		12.00																					12.00																6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4004	066	0	1	02	01	H4004_066_0	4			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	15.00		30.00																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4004	066	0	1	02	01	H4004_066_0	4			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	20.00		40.00																					40.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		40.00						40.00				20.00		20.00
H4004	066	0	1	02	01	H4004_066_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				496.14	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H4004	066	0	1	02	01	H4004_066_0	4			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H4004	066	0	1	02	01	H4004_066_0	4			Select Care Drugs	4	10	1	2	6	3	110		01	100		1	30		90				1	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										2																	
H4005	004	0	1	04	01	H4005_004_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	004	0	1	04	01	H4005_004_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H4005	004	0	1	04	01	H4005_004_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	004	0	1	04	01	H4005_004_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H4005	004	0	1	04	01	H4005_004_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								40.00		80.00					25.00		50.00							50.00																40.00				25.00			1.33	0.83				0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	004	0	1	04	01	H4005_004_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					40.00		80.00							80.00																55.00				40.00			1.83	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	004	0	1	04	01	H4005_004_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	004	0	1	04	01	H4005_004_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H4005	004	0	1	04	01	H4005_004_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4005	007	0	1	04	01	H4005_007_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	007	0	1	04	01	H4005_007_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H4005	007	0	1	04	01	H4005_007_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	007	0	1	04	01	H4005_007_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H4005	007	0	1	04	01	H4005_007_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								40.00		80.00					15.00		30.00							30.00																40.00				15.00			1.33	0.50				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	007	0	1	04	01	H4005_007_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					30.00		60.00							60.00																55.00				30.00			1.83	1.00				0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	007	0	1	04	01	H4005_007_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H4005	007	0	1	04	01	H4005_007_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H4005	007	0	1	04	01	H4005_007_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H4007	012	0	1	01	01	H4007_012_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	012	0	1	01	01	H4007_012_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	012	0	1	01	01	H4007_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	012	0	1	01	01	H4007_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									11.00		33.00				10.00		20.00				10.00				10.00		0.33				0.37	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	012	0	1	01	01	H4007_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	012	0	1	01	01	H4007_012_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	020	0	1	01	01	H4007_020_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	020	0	1	01	01	H4007_020_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	020	0	1	01	01	H4007_020_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									5.00		15.00				5.00		5.00				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	020	0	1	01	01	H4007_020_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									21.00		63.00				20.00		50.00				20.00				20.00		0.67				0.70	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	020	0	1	01	01	H4007_020_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	020	0	1	01	01	H4007_020_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	021	0	1	01	01	H4007_021_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	021	0	1	01	01	H4007_021_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	021	0	1	01	01	H4007_021_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	021	0	1	01	01	H4007_021_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									16.00		48.00				15.00		35.00				15.00				15.00		0.50				0.53	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	021	0	1	01	01	H4007_021_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	021	0	1	01	01	H4007_021_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	024	0	1	01	01	H4007_024_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	024	0	1	01	01	H4007_024_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	024	0	1	01	01	H4007_024_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	024	0	1	01	01	H4007_024_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									16.00		48.00				15.00		35.00				15.00				15.00		0.50				0.53	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	024	0	1	01	01	H4007_024_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	024	0	1	01	01	H4007_024_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									16.00		48.00				15.00		35.00				15.00				15.00		0.50				0.53	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	025	0	1	01	01	H4007_025_0	4			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	028	0	1	02	01	H4007_028_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H4007	029	0	1	01	01	H4007_029_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4036	008	0	1	04	01	H4036_008_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	008	0	1	04	01	H4036_008_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	008	0	1	04	01	H4036_008_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	008	0	1	04	01	H4036_008_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	008	0	1	04	01	H4036_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	008	0	1	04	01	H4036_008_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	008	0	1	04	01	H4036_008_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	017	0	1	04	01	H4036_017_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	017	0	1	04	01	H4036_017_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	017	0	1	04	01	H4036_017_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	017	0	1	04	01	H4036_017_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	017	0	1	04	01	H4036_017_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												32							32						32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	017	0	1	04	01	H4036_017_0	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	017	0	1	04	01	H4036_017_0	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	020	0	1	04	01	H4036_020_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	020	0	1	04	01	H4036_020_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	020	0	1	04	01	H4036_020_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	020	0	1	04	01	H4036_020_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	020	0	1	04	01	H4036_020_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	020	0	1	04	01	H4036_020_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	020	0	1	04	01	H4036_020_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	020	0	1	04	01	H4036_020_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	025	0	1	04	01	H4036_025_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	025	0	1	04	01	H4036_025_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	025	0	1	04	01	H4036_025_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	025	0	1	04	01	H4036_025_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	025	0	1	04	01	H4036_025_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	025	0	1	04	01	H4036_025_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	025	0	1	04	01	H4036_025_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	026	0	1	04	01	H4036_026_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	026	0	1	04	01	H4036_026_0	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	026	0	1	04	01	H4036_026_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	026	0	1	04	01	H4036_026_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	026	0	1	04	01	H4036_026_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	026	0	1	04	01	H4036_026_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	026	0	1	04	01	H4036_026_0	10			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	026	0	1	04	01	H4036_026_0	10			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	028	0	1	04	01	H4036_028_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	028	0	1	04	01	H4036_028_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	028	0	1	04	01	H4036_028_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								46.00	92.00	138.00					41.00	82.00	123.00					41.00	82.00	82.00																46.00				46.00			1.53	1.37	1.37			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	028	0	1	04	01	H4036_028_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	028	0	1	04	01	H4036_028_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	028	0	1	04	01	H4036_028_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	028	0	1	04	01	H4036_028_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	029	0	1	04	01	H4036_029_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	029	0	1	04	01	H4036_029_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	029	0	1	04	01	H4036_029_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H4036	029	0	1	04	01	H4036_029_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	029	0	1	04	01	H4036_029_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	029	0	1	04	01	H4036_029_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	029	0	1	04	01	H4036_029_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	030	0	1	04	01	H4036_030_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	030	0	1	04	01	H4036_030_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	030	0	1	04	01	H4036_030_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	030	0	1	04	01	H4036_030_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	030	0	1	04	01	H4036_030_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	030	0	1	04	01	H4036_030_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	030	0	1	04	01	H4036_030_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	031	0	1	04	01	H4036_031_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	031	0	1	04	01	H4036_031_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	031	0	1	04	01	H4036_031_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H4036	031	0	1	04	01	H4036_031_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	031	0	1	04	01	H4036_031_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	031	0	1	04	01	H4036_031_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	031	0	1	04	01	H4036_031_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	033	0	1	04	01	H4036_033_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	033	0	1	04	01	H4036_033_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	033	0	1	04	01	H4036_033_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	033	0	1	04	01	H4036_033_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	033	0	1	04	01	H4036_033_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	033	0	1	04	01	H4036_033_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	033	0	1	04	01	H4036_033_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	034	0	1	04	01	H4036_034_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	034	0	1	04	01	H4036_034_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								17.00	34.00	51.00					12.00	24.00	36.00					0.00	0.00	0.00																17.00				17.00			0.57	0.40	0.00			0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	034	0	1	04	01	H4036_034_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	034	0	1	04	01	H4036_034_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	034	0	1	04	01	H4036_034_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	034	0	1	04	01	H4036_034_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	034	0	1	04	01	H4036_034_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	035	0	1	04	01	H4036_035_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	035	0	1	04	01	H4036_035_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	035	0	1	04	01	H4036_035_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	035	0	1	04	01	H4036_035_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	035	0	1	04	01	H4036_035_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	035	0	1	04	01	H4036_035_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	035	0	1	04	01	H4036_035_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	035	0	1	04	01	H4036_035_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	036	0	1	04	01	H4036_036_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	036	0	1	04	01	H4036_036_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4036	036	0	1	04	01	H4036_036_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								17.00	34.00	51.00					12.00	24.00	36.00					0.00	0.00	0.00																17.00				17.00			0.57	0.40	0.00			0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	036	0	1	04	01	H4036_036_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4036	036	0	1	04	01	H4036_036_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	036	0	1	04	01	H4036_036_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	036	0	1	04	01	H4036_036_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4036	036	0	1	04	01	H4036_036_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4073	001	0	1	01	01	H4073_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4073	001	0	1	01	01	H4073_001_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4073	001	0	1	01	01	H4073_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4073	001	0	1	01	01	H4073_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.55	50	50	50				98.55	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4073	001	0	1	01	01	H4073_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4073	001	0	1	01	01	H4073_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4091	003	0	1	04	01	H4091_003_0	7			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	4.00	8.00	12.00																			4.00	8.00	12.00																	4.00			4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H4091	003	0	1	04	01	H4091_003_0	7			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H4091	003	0	1	04	01	H4091_003_0	7			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4091	003	0	1	04	01	H4091_003_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4091	003	0	1	04	01	H4091_003_0	7			Specialty Tier	4	11	1	1	5	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31					30	30	30																		30	30	30																30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H4140	001	0	1	01	01	H4140_001_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	001	0	1	01	01	H4140_001_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	001	0	1	01	01	H4140_001_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	001	0	1	01	01	H4140_001_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	001	0	1	01	01	H4140_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	001	0	1	01	01	H4140_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	001	0	1	01	01	H4140_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				669.92	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	001	0	1	01	01	H4140_001_0	11			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	001	0	1	01	01	H4140_001_0	11			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	002	0	1	01	01	H4140_002_0	11		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	002	0	1	01	01	H4140_002_0	11		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	002	0	1	01	01	H4140_002_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	002	0	1	01	01	H4140_002_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	002	0	1	01	01	H4140_002_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	002	0	1	01	01	H4140_002_0	11		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	002	0	1	01	01	H4140_002_0	11		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	004	0	1	01	01	H4140_004_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	004	0	1	01	01	H4140_004_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	004	0	1	01	01	H4140_004_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	004	0	1	01	01	H4140_004_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	004	0	1	01	01	H4140_004_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H4140	004	0	1	01	01	H4140_004_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	004	0	1	01	01	H4140_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				848.54	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	004	0	1	01	01	H4140_004_0	11			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	004	0	1	01	01	H4140_004_0	11			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	005	0	1	01	01	H4140_005_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	005	0	1	01	01	H4140_005_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	005	0	1	01	01	H4140_005_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	005	0	1	01	01	H4140_005_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	005	0	1	01	01	H4140_005_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	005	0	1	01	01	H4140_005_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	90.00	180.00	270.00																			90.00	180.00	270.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	005	0	1	01	01	H4140_005_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				739.69	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	005	0	1	01	01	H4140_005_0	11			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	005	0	1	01	01	H4140_005_0	11			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	009	0	1	01	01	H4140_009_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	009	0	1	01	01	H4140_009_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	009	0	1	01	01	H4140_009_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	009	0	1	01	01	H4140_009_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	009	0	1	01	01	H4140_009_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	009	0	1	01	01	H4140_009_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	009	0	1	01	01	H4140_009_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				669.26	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	009	0	1	01	01	H4140_009_0	11			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	009	0	1	01	01	H4140_009_0	11			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	010	0	1	01	01	H4140_010_0	11		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	010	0	1	01	01	H4140_010_0	11		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	010	0	1	01	01	H4140_010_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	010	0	1	01	01	H4140_010_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	010	0	1	01	01	H4140_010_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	010	0	1	01	01	H4140_010_0	11		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	010	0	1	01	01	H4140_010_0	11		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	011	0	1	01	01	H4140_011_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	011	0	1	01	01	H4140_011_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	011	0	1	01	01	H4140_011_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	011	0	1	01	01	H4140_011_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	011	0	1	01	01	H4140_011_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	011	0	1	01	01	H4140_011_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	011	0	1	01	01	H4140_011_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				699.42	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	011	0	1	01	01	H4140_011_0	11			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	011	0	1	01	01	H4140_011_0	11			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	012	0	1	01	01	H4140_012_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	012	0	1	01	01	H4140_012_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	012	0	1	01	01	H4140_012_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	012	0	1	01	01	H4140_012_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	012	0	1	01	01	H4140_012_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4140	012	0	1	01	01	H4140_012_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	012	0	1	01	01	H4140_012_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				696.82	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	012	0	1	01	01	H4140_012_0	11			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	012	0	1	01	01	H4140_012_0	11			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4140	013	0	1	01	01	H4140_013_0	11		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	013	0	1	01	01	H4140_013_0	11		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	013	0	1	01	01	H4140_013_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	013	0	1	01	01	H4140_013_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4140	013	0	1	01	01	H4140_013_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	013	0	1	01	01	H4140_013_0	11		N	Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H4140	013	0	1	01	01	H4140_013_0	11		N	Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	1	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H4141	015	0	1	01	01	H4141_015_0	10			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4141	015	0	1	01	01	H4141_015_0	10			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4141	015	0	1	01	01	H4141_015_0	10			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4141	015	0	1	01	01	H4141_015_0	10			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4141	015	0	1	01	01	H4141_015_0	10			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4141	015	0	1	01	01	H4141_015_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4141	015	0	1	01	01	H4141_015_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4141	017	3	1	01	01	H4141_017_3	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4141	017	3	1	01	01	H4141_017_3	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4141	017	3	1	01	01	H4141_017_3	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4141	017	3	1	01	01	H4141_017_3	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4141	017	3	1	01	01	H4141_017_3	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4141	017	3	1	01	01	H4141_017_3	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4141	017	3	1	01	01	H4141_017_3	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4141	017	5	1	01	01	H4141_017_5	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4141	017	5	1	01	01	H4141_017_5	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4141	017	5	1	01	01	H4141_017_5	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4141	017	5	1	01	01	H4141_017_5	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4141	017	5	1	01	01	H4141_017_5	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4141	017	5	1	01	01	H4141_017_5	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4141	017	5	1	01	01	H4141_017_5	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4152	005	0	1	01	01	H4152_005_0	7			Preferred Generic	4	01	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					3.00	6.00	9.00												22.00	33.00					0.00	0.00				11.00				3.00			0.37	0.10				0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00	3.00	6.00	9.00		22.00	33.00		0.00	0.00	11.00		3.00
H4152	005	0	1	01	01	H4152_005_0	7			Generic	4	01	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								14.00	28.00	42.00					6.00	12.00	18.00												28.00	42.00					0.00	0.00				14.00				6.00			0.47	0.20				0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00	6.00	12.00	18.00		28.00	42.00		0.00	0.00	14.00		6.00
H4152	005	0	1	01	01	H4152_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					94.00	117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00		40.00	60.00		40.00	50.00	20.00		20.00
H4152	005	0	1	01	01	H4152_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	250.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00
H4152	005	0	1	01	01	H4152_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4152	007	0	1	02	01	H4152_007_0	7			Preferred Generic	4	01	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					3.00	6.00	9.00												22.00	33.00					0.00	0.00				11.00				3.00			0.37	0.10				0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	33.00	3.00	6.00	9.00		22.00	33.00		0.00	0.00	11.00		3.00
H4152	007	0	1	02	01	H4152_007_0	7			Preferred Generic	4	01	1	2	1	3		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					3.00	6.00	9.00												22.00	33.00					0.00	0.00				11.00				3.00			0.37	0.10				0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4152	007	0	1	02	01	H4152_007_0	7			Generic	4	01	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								14.00	28.00	42.00					6.00	12.00	18.00												28.00	42.00					0.00	0.00				14.00				6.00			0.47	0.20				0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00	6.00	12.00	18.00		28.00	42.00		0.00	0.00	14.00		6.00
H4152	007	0	1	02	01	H4152_007_0	7			Generic	4	01	1	2	2	3		111	01		101	1				30	60	90	1	2					60	90	30		31								14.00	28.00	42.00					6.00	12.00	18.00												28.00	42.00					0.00	0.00				14.00				6.00			0.47	0.20				0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4152	007	0	1	02	01	H4152_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					94.00	117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00		40.00	60.00		40.00	50.00	20.00		20.00
H4152	007	0	1	02	01	H4152_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	250.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00
H4152	007	0	1	02	01	H4152_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4152	013	0	1	01	01	H4152_013_0	7			Preferred Generic	4	01	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					0.00	0.00				8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00		16.00	24.00		0.00	0.00	8.00		0.00
H4152	013	0	1	01	01	H4152_013_0	7			Generic	4	01	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								16.00	32.00	48.00					0.00	0.00	0.00												32.00	48.00					0.00	0.00				16.00				0.00			0.53	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													16.00	32.00	48.00	0.00	0.00	0.00		32.00	48.00		0.00	0.00	16.00		0.00
H4152	013	0	1	01	01	H4152_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					94.00	117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00		40.00	60.00		40.00	50.00	20.00		20.00
H4152	013	0	1	01	01	H4152_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	250.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00
H4152	013	0	1	01	01	H4152_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4152	018	0	1	02	01	H4152_018_0	7			Preferred Generic	4	01	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					0.00	0.00				8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00		16.00	24.00		0.00	0.00	8.00		0.00
H4152	018	0	1	02	01	H4152_018_0	7			Generic	4	01	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								12.00	24.00	36.00					4.00	8.00	12.00												24.00	36.00					0.00	0.00				12.00				4.00			0.40	0.13				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	4.00	8.00	12.00		24.00	36.00		0.00	0.00	12.00		4.00
H4152	018	0	1	02	01	H4152_018_0	7			Preferred Brand	4	11	1	2	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					94.00	117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00		40.00	60.00		40.00	50.00	20.00		20.00
H4152	018	0	1	02	01	H4152_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	250.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00
H4152	018	0	1	02	01	H4152_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4152	020	0	1	02	01	H4152_020_0	8			Preferred Generic	4	01	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					0.00	0.00				8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00		16.00	24.00		0.00	0.00	8.00		0.00
H4152	020	0	1	02	01	H4152_020_0	8			Generic	4	01	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								16.00	32.00	48.00					0.00	0.00	0.00												32.00	48.00					0.00	0.00				16.00				0.00			0.53	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													16.00	32.00	48.00	0.00	0.00	0.00		32.00	48.00		0.00	0.00	16.00		0.00
H4152	020	0	1	02	01	H4152_020_0	8			Preferred Brand	4	11	1	2	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					94.00	117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00		40.00	60.00		40.00	50.00	20.00		20.00
H4152	020	0	1	02	01	H4152_020_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	250.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00
H4152	020	0	1	02	01	H4152_020_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	002	0	1	01	01	H4161_002_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	002	0	1	01	01	H4161_002_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4161	002	0	1	01	01	H4161_002_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	002	0	1	01	01	H4161_002_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	002	0	1	01	01	H4161_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	002	0	1	01	01	H4161_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	002	0	1	01	01	H4161_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	003	0	1	01	01	H4161_003_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	003	0	1	01	01	H4161_003_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	003	0	1	01	01	H4161_003_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	003	0	1	01	01	H4161_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	003	0	1	01	01	H4161_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	003	0	1	01	01	H4161_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	004	0	1	01	01	H4161_004_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	004	0	1	01	01	H4161_004_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	004	0	1	01	01	H4161_004_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.00	24.00	36.00					7.00	14.00	21.00					0.00	0.00	0.00																12.00				12.00			0.40	0.23	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	004	0	1	01	01	H4161_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4161	004	0	1	01	01	H4161_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	004	0	1	01	01	H4161_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	005	0	1	01	01	H4161_005_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	005	0	1	01	01	H4161_005_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	005	0	1	01	01	H4161_005_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.00	24.00	36.00					7.00	14.00	21.00					0.00	0.00	0.00																12.00				12.00			0.40	0.23	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	005	0	1	01	01	H4161_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	005	0	1	01	01	H4161_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	005	0	1	01	01	H4161_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	006	0	1	01	01	H4161_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	006	0	1	01	01	H4161_006_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	006	0	1	01	01	H4161_006_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.00	24.00	36.00					7.00	14.00	21.00					0.00	0.00	0.00																12.00				12.00			0.40	0.23	0.00			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	006	0	1	01	01	H4161_006_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4161	006	0	1	01	01	H4161_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	006	0	1	01	01	H4161_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	007	0	1	01	01	H4161_007_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	007	0	1	01	01	H4161_007_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	007	0	1	01	01	H4161_007_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	007	0	1	01	01	H4161_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4161	007	0	1	01	01	H4161_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	007	0	1	01	01	H4161_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	009	0	1	01	01	H4161_009_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	009	0	1	01	01	H4161_009_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4161	009	0	1	01	01	H4161_009_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	009	0	1	01	01	H4161_009_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	009	0	1	01	01	H4161_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	009	0	1	01	01	H4161_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	009	0	1	01	01	H4161_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	010	0	1	01	01	H4161_010_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	010	0	1	01	01	H4161_010_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4161	010	0	1	01	01	H4161_010_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	010	0	1	01	01	H4161_010_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4161	010	0	1	01	01	H4161_010_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	010	0	1	01	01	H4161_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	010	0	1	01	01	H4161_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4161	011	0	1	01	01	H4161_011_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	011	0	1	01	01	H4161_011_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4161	011	0	1	01	01	H4161_011_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	011	0	1	01	01	H4161_011_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4161	011	0	1	01	01	H4161_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								35.00	70.00	105.00					30.00	60.00	90.00					30.00	60.00	60.00																35.00				35.00			1.17	1.00	1.00			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H4161	011	0	1	01	01	H4161_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	011	0	1	01	01	H4161_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	011	0	1	01	01	H4161_011_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H4161	011	0	1	01	01	H4161_011_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4161	012	0	1	01	01	H4161_012_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	012	0	1	01	01	H4161_012_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	012	0	1	01	01	H4161_012_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								40.00	80.00	120.00					30.00	60.00	90.00					30.00	60.00	60.00																40.00				40.00			1.33	1.00	1.00			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00
H4161	012	0	1	01	01	H4161_012_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	012	0	1	01	01	H4161_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	012	0	1	01	01	H4161_012_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H4161	012	0	1	01	01	H4161_012_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4161	013	0	1	01	01	H4161_013_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	013	0	1	01	01	H4161_013_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4161	013	0	1	01	01	H4161_013_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	013	0	1	01	01	H4161_013_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4161	013	0	1	01	01	H4161_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								40.00	80.00	120.00					35.00	70.00	105.00					35.00	70.00	70.00																40.00				40.00			1.33	1.17	1.17			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	013	0	1	01	01	H4161_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4161	013	0	1	01	01	H4161_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33						15.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4161	013	0	1	01	01	H4161_013_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H4161	013	0	1	01	01	H4161_013_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4198	008	0	1	01	01	H4198_008_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4198	008	0	1	01	01	H4198_008_0	4			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4198	008	0	1	01	01	H4198_008_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H4198	008	0	1	01	01	H4198_008_0	4			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4198	008	0	1	01	01	H4198_008_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4198	008	0	1	01	01	H4198_008_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4198	008	0	1	01	01	H4198_008_0	4			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1782.00	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4198	009	0	1	01	01	H4198_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4198	009	0	1	01	01	H4198_009_0	5			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4198	009	0	1	01	01	H4198_009_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H4198	009	0	1	01	01	H4198_009_0	5			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4198	009	0	1	01	01	H4198_009_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4198	009	0	1	01	01	H4198_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4198	009	0	1	01	01	H4198_009_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1744.51	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4213	017	1	1	09	04	H4213_017_1	3			Preferred Generic	3	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	15.00		37.50																			15.00		37.50																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	1	1	09	04	H4213_017_1	3			Generic	3	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	20.00		50.00																			20.00		50.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	1	1	09	04	H4213_017_1	3			Preferred Brand	3	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		117.50																			47.00		117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		87.50				35.00		87.50				35.00		35.00
H4213	017	1	1	09	04	H4213_017_1	3			Non-Preferred Drug	3	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				67.74	32		32																		32		32															32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		87.50				35.00		87.50				35.00		35.00
H4213	017	1	1	09	04	H4213_017_1	3			Specialty Tier	3	11	1	1	5	1	010		01	010		1	30								30						30		31				1178.12	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H4213	017	1	1	09	04	H4213_017_1	3			Select Care Drugs	3	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	5	1	09	04	H4213_017_5	3			Preferred Generic	3	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	15.00		37.50																			15.00		37.50																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	5	1	09	04	H4213_017_5	3			Generic	3	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	20.00		50.00																			20.00		50.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	5	1	09	04	H4213_017_5	3			Preferred Brand	3	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		117.50																			47.00		117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		87.50				35.00		87.50				35.00		35.00
H4213	017	5	1	09	04	H4213_017_5	3			Non-Preferred Drug	3	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				67.74	32		32																		32		32															32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		87.50				35.00		87.50				35.00		35.00
H4213	017	5	1	09	04	H4213_017_5	3			Specialty Tier	3	11	1	1	5	1	010		01	010		1	30								30						30		31				1178.12	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H4213	017	5	1	09	04	H4213_017_5	3			Select Care Drugs	3	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	6	1	09	04	H4213_017_6	3			Preferred Generic	3	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	15.00		37.50																			15.00		37.50																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	6	1	09	04	H4213_017_6	3			Generic	3	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	20.00		50.00																			20.00		50.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4213	017	6	1	09	04	H4213_017_6	3			Preferred Brand	3	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		117.50																			47.00		117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		87.50				35.00		87.50				35.00		35.00
H4213	017	6	1	09	04	H4213_017_6	3			Non-Preferred Drug	3	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				67.74	32		32																		32		32															32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		87.50				35.00		87.50				35.00		35.00
H4213	017	6	1	09	04	H4213_017_6	3			Specialty Tier	3	11	1	1	5	1	010		01	010		1	30								30						30		31				1178.12	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H4213	017	6	1	09	04	H4213_017_6	3			Select Care Drugs	3	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4277	001	0	1	04	01	H4277_001_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4277	001	0	1	04	01	H4277_001_0	5			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4277	001	0	1	04	01	H4277_001_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H4277	001	0	1	04	01	H4277_001_0	5			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4277	001	0	1	04	01	H4277_001_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4277	001	0	1	04	01	H4277_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4277	001	0	1	04	01	H4277_001_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1749.81	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4279	001	0	1	01	01	H4279_001_0	8		N	Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	45.00					5.00	7.50	10.00													15.00						10.00				15.00				5.00			0.50	0.17				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	001	0	1	01	01	H4279_001_0	8		N	Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	60.00					15.00	22.50	30.00													35.00						30.00				20.00				15.00			0.67	0.50				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	001	0	1	01	01	H4279_001_0	8		N	Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					35.00	52.50	70.00													75.00						70.00				47.00				35.00			1.57	1.17				1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	52.50	70.00			75.00			70.00	35.00		35.00
H4279	001	0	1	01	01	H4279_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	100	1	2						100	30		31											64.45	49	49	49				68.28	49	49	49												49						49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	001	0	1	01	01	H4279_001_0	8		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.53	25						756.09	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	004	0	1	01	01	H4279_004_0	8		N	Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	45.00					5.00	7.50	10.00													15.00						10.00				15.00				5.00			0.50	0.17				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	004	0	1	01	01	H4279_004_0	8		N	Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	60.00					15.00	22.50	30.00													35.00						30.00				20.00				15.00			0.67	0.50				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	004	0	1	01	01	H4279_004_0	8		N	Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					35.00	52.50	70.00													75.00						70.00				47.00				35.00			1.57	1.17				1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	52.50	70.00			75.00			70.00	35.00		35.00
H4279	004	0	1	01	01	H4279_004_0	8		N	Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	100	1	2						100	30		31											69.43	49	49	49				67.07	49	49	49												49						49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4279	004	0	1	01	01	H4279_004_0	8		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.10	25						807.84	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4286	001	0	1	01	01	H4286_001_0	10			Generic	4	01	3	2	1	1		111	01			1				30	60	90	2	2							30		31								5.00	10.00	15.00					0.00	0.00	0.00																							5.00				5.00			0.17	0.00				0.16	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00							5.00		5.00
H4286	001	0	1	01	01	H4286_001_0	10			Generic	4	01	3	2	1	3		111	01			1				30	60	90	2	2							30		31								5.00	10.00	15.00					0.00	0.00	0.00																							5.00				5.00			0.17	0.00				0.16	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H4286	001	0	1	01	01	H4286_001_0	10			Preferred Brand	4	11	1	2	2	1		111	01			1				30	60	90	2	2							30		31								20.00	40.00	60.00					0.00	0.00	0.00																							20.00				20.00			0.67	0.00				0.65	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00							20.00		20.00
H4286	001	0	1	01	01	H4286_001_0	10			Non-Preferred Brand	4	11	1	2	3	1		010	01			1				30											30		31								50.00							40.00																									50.00				50.00			1.67	1.33				1.61	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00									35.00		35.00
H4286	001	0	1	01	01	H4286_001_0	10			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											3712.03	33						350.00	33																							33			33								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H4286	002	0	1	01	01	H4286_002_0	11		N	Generic	4	11	1	1	1	1		111	01			1				30	60	90	2	2							30		31											3.38	24	24	24				1.53	24	24	24																					24			24								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00	35.00	70.00	105.00							35.00		35.00
H4286	002	0	1	01	01	H4286_002_0	11		N	Preferred Brand	4	11	1	1	2	1		111	01			1				30	60	90	2	2							30		31											77.37	24	24	24				77.72	24	24	24																					24			24								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00	35.00	70.00	105.00							35.00		35.00
H4286	002	0	1	01	01	H4286_002_0	11		N	Non-Preferred Brand	4	11	1	1	3	1		010	01			1				30											30		31											69.59	28						69.59	28																							28			28								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00			35.00									35.00		35.00
H4286	002	0	1	01	01	H4286_002_0	11		N	Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											1285.42	25						1285.42	25																							25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H4286	002	0	1	01	01	H4286_002_0	11		N	Supplemental Drugs	4	01	2	2	5	1		010	01			1				30											30		31								10.00							0.00																									10.00				10.00			0.33	0.00				0.32	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H4286	002	0	1	01	01	H4286_002_0	11		N	Supplemental Drugs	4	01	2	2	5	3		010	01			1				30											30		31								10.00							0.00																									10.00				10.00			0.33	0.00				0.32	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H4286	003	0	1	01	01	H4286_003_0	9			Generic	4	11	3	2	1	1		111	01			1				30	60	90	2	2							30		31								10.00	20.00	30.00					0.00	0.00	0.00																							10.00				10.00			0.33	0.00				0.32	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00							10.00		10.00
H4286	003	0	1	01	01	H4286_003_0	9			Generic	4	11	3	2	1	3		111	01			1				30	60	90	2	2							30		31								10.00	20.00	30.00					0.00	0.00	0.00																							10.00				10.00			0.33	0.00				0.32	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H4286	003	0	1	01	01	H4286_003_0	9			Preferred Brand	4	11	1	2	2	1		111	01			1				30	60	90	2	2							30		31								47.00	94.00	141.00					47.00	94.00	141.00																							47.00				47.00			1.57	1.57				1.52	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00							35.00		35.00
H4286	003	0	1	01	01	H4286_003_0	9			Non-Preferred Brand	4	11	1	2	3	1		010	01			1				30											30		31								100.00							97.00																									100.00				100.00			3.33	3.23				3.23	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00									35.00		35.00
H4286	003	0	1	01	01	H4286_003_0	9			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											485.79	33						485.79	33																							33			33								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H4343	001	0	1	01	01	H4343_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4343	001	0	1	01	01	H4343_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4343	001	0	1	01	01	H4343_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4343	001	0	1	01	01	H4343_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.14	50	50	50				77.14	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4343	001	0	1	01	01	H4343_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4343	001	0	1	01	01	H4343_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4343	003	0	1	01	01	H4343_003_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4343	003	0	1	01	01	H4343_003_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4343	003	0	1	01	01	H4343_003_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4343	003	0	1	01	01	H4343_003_0	18			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4343	003	0	1	01	01	H4343_003_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4343	003	0	1	01	01	H4343_003_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.79	50	50	50				80.79	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4343	003	0	1	01	01	H4343_003_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4343	003	0	1	01	01	H4343_003_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4343	003	0	1	01	01	H4343_003_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4346	001	0	1	01	01	H4346_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	001	0	1	01	01	H4346_001_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	001	0	1	01	01	H4346_001_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	001	0	1	01	01	H4346_001_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	001	0	1	01	01	H4346_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	001	0	1	01	01	H4346_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	001	0	1	01	01	H4346_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	001	0	1	01	01	H4346_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H4346	001	0	1	01	01	H4346_001_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	005	0	1	01	01	H4346_005_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	005	0	1	01	01	H4346_005_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	005	0	1	01	01	H4346_005_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	005	0	1	01	01	H4346_005_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	005	0	1	01	01	H4346_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	005	0	1	01	01	H4346_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	005	0	1	01	01	H4346_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	005	0	1	01	01	H4346_005_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H4346	005	0	1	01	01	H4346_005_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	006	0	1	01	01	H4346_006_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	006	0	1	01	01	H4346_006_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	006	0	1	01	01	H4346_006_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	006	0	1	01	01	H4346_006_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	006	0	1	01	01	H4346_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	006	0	1	01	01	H4346_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	006	0	1	01	01	H4346_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	006	0	1	01	01	H4346_006_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H4346	006	0	1	01	01	H4346_006_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	009	0	1	01	01	H4346_009_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	009	0	1	01	01	H4346_009_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.50	31.00	46.50					10.50	21.00	31.50					0.00	0.00	0.00																15.50				15.50			0.52	0.35	0.00			0.46	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	009	0	1	01	01	H4346_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	009	0	1	01	01	H4346_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					90.00	180.00	270.00					90.00	180.00	180.00																95.00				95.00			3.17	3.00	3.00			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	009	0	1	01	01	H4346_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	009	0	1	01	01	H4346_009_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00	10.00	20.00	30.00	10.00	20.00	20.00				10.00		10.00
H4346	009	0	1	01	01	H4346_009_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	20.00	20.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	010	0	1	01	01	H4346_010_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	010	0	1	01	01	H4346_010_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	010	0	1	01	01	H4346_010_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	010	0	1	01	01	H4346_010_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	010	0	1	01	01	H4346_010_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4346	010	0	1	01	01	H4346_010_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H4346	010	0	1	01	01	H4346_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	010	0	1	01	01	H4346_010_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4346	010	0	1	01	01	H4346_010_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	012	0	1	01	01	H4346_012_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	012	0	1	01	01	H4346_012_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	012	0	1	01	01	H4346_012_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4346	012	0	1	01	01	H4346_012_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	012	0	1	01	01	H4346_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	012	0	1	01	01	H4346_012_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	012	0	1	01	01	H4346_012_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4346	017	0	1	01	01	H4346_017_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	017	0	1	01	01	H4346_017_0	7			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4346	017	0	1	01	01	H4346_017_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	017	0	1	01	01	H4346_017_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4346	017	0	1	01	01	H4346_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	017	0	1	01	01	H4346_017_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	019	0	1	01	01	H4346_019_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	019	0	1	01	01	H4346_019_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4346	019	0	1	01	01	H4346_019_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	019	0	1	01	01	H4346_019_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4346	019	0	1	01	01	H4346_019_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	019	0	1	01	01	H4346_019_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4346	029	0	1	01	01	H4346_029_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	029	0	1	01	01	H4346_029_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	029	0	1	01	01	H4346_029_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4346	029	0	1	01	01	H4346_029_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	029	0	1	01	01	H4346_029_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	029	0	1	01	01	H4346_029_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4346	029	0	1	01	01	H4346_029_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4407	027	0	1	01	01	H4407_027_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4407	027	0	1	01	01	H4407_027_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4407	027	0	1	01	01	H4407_027_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4407	027	0	1	01	01	H4407_027_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	027	0	1	01	01	H4407_027_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	027	0	1	01	01	H4407_027_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											807.43	33						429.22	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4407	028	0	1	01	01	H4407_028_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4407	028	0	1	01	01	H4407_028_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4407	028	0	1	01	01	H4407_028_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H4407	028	0	1	01	01	H4407_028_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	028	0	1	01	01	H4407_028_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	028	0	1	01	01	H4407_028_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											676.08	33						484.64	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4407	030	1	1	01	01	H4407_030_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4407	030	1	1	01	01	H4407_030_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4407	030	1	1	01	01	H4407_030_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4407	030	1	1	01	01	H4407_030_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	030	1	1	01	01	H4407_030_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	030	1	1	01	01	H4407_030_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											736.72	33						581.19	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4407	030	2	1	01	01	H4407_030_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4407	030	2	1	01	01	H4407_030_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4407	030	2	1	01	01	H4407_030_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4407	030	2	1	01	01	H4407_030_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	030	2	1	01	01	H4407_030_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	030	2	1	01	01	H4407_030_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											736.72	33						581.19	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4407	030	3	1	01	01	H4407_030_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4407	030	3	1	01	01	H4407_030_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4407	030	3	1	01	01	H4407_030_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4407	030	3	1	01	01	H4407_030_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	030	3	1	01	01	H4407_030_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4407	030	3	1	01	01	H4407_030_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											736.72	33						581.19	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4461	025	0	1	01	01	H4461_025_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	025	0	1	01	01	H4461_025_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4461	025	0	1	01	01	H4461_025_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	025	0	1	01	01	H4461_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	025	0	1	01	01	H4461_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4461	029	0	1	01	01	H4461_029_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	029	0	1	01	01	H4461_029_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H4461	029	0	1	01	01	H4461_029_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	029	0	1	01	01	H4461_029_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	029	0	1	01	01	H4461_029_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4461	035	0	1	01	01	H4461_035_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	035	0	1	01	01	H4461_035_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4461	035	0	1	01	01	H4461_035_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	035	0	1	01	01	H4461_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	035	0	1	01	01	H4461_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4461	039	0	1	01	01	H4461_039_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	039	0	1	01	01	H4461_039_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H4461	039	0	1	01	01	H4461_039_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	039	0	1	01	01	H4461_039_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	039	0	1	01	01	H4461_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4461	040	0	1	01	01	H4461_040_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	040	0	1	01	01	H4461_040_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4461	040	0	1	01	01	H4461_040_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	040	0	1	01	01	H4461_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	040	0	1	01	01	H4461_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4461	041	0	1	01	01	H4461_041_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4461	041	0	1	01	01	H4461_041_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4461	041	0	1	01	01	H4461_041_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	041	0	1	01	01	H4461_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	041	0	1	01	01	H4461_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4461	042	0	1	01	01	H4461_042_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
H4461	042	0	1	01	01	H4461_042_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H4461	042	0	1	01	01	H4461_042_0	7			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	12		12																								12		12				12		12			12			12								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	042	0	1	01	01	H4461_042_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	33		33																								33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4461	042	0	1	01	01	H4461_042_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4471	002	0	1	01	01	H4471_002_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4471	002	0	1	01	01	H4471_002_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4471	002	0	1	01	01	H4471_002_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				109.97	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4471	002	0	1	01	01	H4471_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				49.64	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4471	002	0	1	01	01	H4471_002_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	1	1	04	01	H4497_001_1	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	1	1	04	01	H4497_001_1	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	001	1	1	04	01	H4497_001_1	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	1	1	04	01	H4497_001_1	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	001	1	1	04	01	H4497_001_1	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	001	1	1	04	01	H4497_001_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.63	50	50	50				63.11	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	1	1	04	01	H4497_001_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	2	1	04	01	H4497_001_2	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	2	1	04	01	H4497_001_2	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	001	2	1	04	01	H4497_001_2	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	2	1	04	01	H4497_001_2	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	001	2	1	04	01	H4497_001_2	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	001	2	1	04	01	H4497_001_2	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.63	50	50	50				63.11	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	2	1	04	01	H4497_001_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	3	1	04	01	H4497_001_3	15			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	3	1	04	01	H4497_001_3	15			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	001	3	1	04	01	H4497_001_3	15			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	3	1	04	01	H4497_001_3	15			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	001	3	1	04	01	H4497_001_3	15			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	001	3	1	04	01	H4497_001_3	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.63	50	50	50				63.11	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	001	3	1	04	01	H4497_001_3	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	1	1	04	01	H4497_002_1	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	1	1	04	01	H4497_002_1	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	002	1	1	04	01	H4497_002_1	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	1	1	04	01	H4497_002_1	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	002	1	1	04	01	H4497_002_1	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	002	1	1	04	01	H4497_002_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.68	50	50	50				64.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	1	1	04	01	H4497_002_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	2	1	04	01	H4497_002_2	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	2	1	04	01	H4497_002_2	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	002	2	1	04	01	H4497_002_2	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	2	1	04	01	H4497_002_2	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	002	2	1	04	01	H4497_002_2	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	002	2	1	04	01	H4497_002_2	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.68	50	50	50				64.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	2	1	04	01	H4497_002_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	3	1	04	01	H4497_002_3	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	3	1	04	01	H4497_002_3	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	002	3	1	04	01	H4497_002_3	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	3	1	04	01	H4497_002_3	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	002	3	1	04	01	H4497_002_3	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	002	3	1	04	01	H4497_002_3	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.68	50	50	50				64.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	002	3	1	04	01	H4497_002_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	1	1	04	01	H4497_003_1	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	1	1	04	01	H4497_003_1	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	003	1	1	04	01	H4497_003_1	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	1	1	04	01	H4497_003_1	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	003	1	1	04	01	H4497_003_1	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	003	1	1	04	01	H4497_003_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.99	50	50	50				55.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	1	1	04	01	H4497_003_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	2	1	04	01	H4497_003_2	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	2	1	04	01	H4497_003_2	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	003	2	1	04	01	H4497_003_2	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	2	1	04	01	H4497_003_2	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	003	2	1	04	01	H4497_003_2	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	003	2	1	04	01	H4497_003_2	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.99	50	50	50				55.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	2	1	04	01	H4497_003_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	3	1	04	01	H4497_003_3	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	3	1	04	01	H4497_003_3	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	003	3	1	04	01	H4497_003_3	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	3	1	04	01	H4497_003_3	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4497	003	3	1	04	01	H4497_003_3	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	003	3	1	04	01	H4497_003_3	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.99	50	50	50				55.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	003	3	1	04	01	H4497_003_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4497	005	3	1	04	01	H4497_005_3	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					4.00	8.00	10.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.13		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	3	1	04	01	H4497_005_3	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					4.00	8.00	10.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.13		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4497	005	3	1	04	01	H4497_005_3	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					8.00	16.00	20.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.27		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	3	1	04	01	H4497_005_3	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					8.00	16.00	20.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.27		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4497	005	3	1	04	01	H4497_005_3	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	005	3	1	04	01	H4497_005_3	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.89	50	50	50				61.28	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	3	1	04	01	H4497_005_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	3	1	04	01	H4497_005_3	12			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	3	1	04	01	H4497_005_3	12			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4497	005	4	1	04	01	H4497_005_4	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					4.00	8.00	10.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.13		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	4	1	04	01	H4497_005_4	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					4.00	8.00	10.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.13		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4497	005	4	1	04	01	H4497_005_4	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					8.00	16.00	20.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.27		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	4	1	04	01	H4497_005_4	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					8.00	16.00	20.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.27		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4497	005	4	1	04	01	H4497_005_4	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4497	005	4	1	04	01	H4497_005_4	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.89	50	50	50				61.28	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	4	1	04	01	H4497_005_4	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	4	1	04	01	H4497_005_4	12			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4497	005	4	1	04	01	H4497_005_4	12			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4506	003	0	1	01	01	H4506_003_0	21			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4506	003	0	1	01	01	H4506_003_0	21			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4506	003	0	1	01	01	H4506_003_0	21			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4506	003	0	1	01	01	H4506_003_0	21			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4506	003	0	1	01	01	H4506_003_0	21			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4506	003	0	1	01	01	H4506_003_0	21			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.58	49	49	49				99.58	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4506	003	0	1	01	01	H4506_003_0	21			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4506	003	0	1	01	01	H4506_003_0	21			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4506	003	0	1	01	01	H4506_003_0	21			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4506	029	0	1	02	01	H4506_029_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4506	029	0	1	02	01	H4506_029_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4506	029	0	1	02	01	H4506_029_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4506	029	0	1	02	01	H4506_029_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4506	029	0	1	02	01	H4506_029_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.85	50	50	50				90.85	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4506	029	0	1	02	01	H4506_029_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4506	029	0	1	02	01	H4506_029_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4506	029	0	1	02	01	H4506_029_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4513	026	0	1	01	01	H4513_026_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	026	0	1	01	01	H4513_026_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	026	0	1	01	01	H4513_026_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	026	0	1	01	01	H4513_026_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	026	0	1	01	01	H4513_026_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	026	0	1	01	01	H4513_026_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											609.73	33						500.97	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	030	0	1	01	01	H4513_030_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	030	0	1	01	01	H4513_030_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	030	0	1	01	01	H4513_030_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H4513	030	0	1	01	01	H4513_030_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	030	0	1	01	01	H4513_030_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	030	0	1	01	01	H4513_030_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											570.41	30						398.15	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	036	0	1	02	01	H4513_036_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	036	0	1	02	01	H4513_036_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	036	0	1	02	01	H4513_036_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	036	0	1	02	01	H4513_036_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	036	0	1	02	01	H4513_036_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	036	0	1	02	01	H4513_036_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											682.94	33						404.63	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	037	0	1	01	01	H4513_037_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	037	0	1	01	01	H4513_037_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	037	0	1	01	01	H4513_037_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H4513	037	0	1	01	01	H4513_037_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	037	0	1	01	01	H4513_037_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	037	0	1	01	01	H4513_037_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.63	33						420.29	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	038	0	1	01	01	H4513_038_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	038	0	1	01	01	H4513_038_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	038	0	1	01	01	H4513_038_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4513	038	0	1	01	01	H4513_038_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	038	0	1	01	01	H4513_038_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	038	0	1	01	01	H4513_038_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											537.60	33						553.59	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	046	1	1	01	01	H4513_046_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	046	1	1	01	01	H4513_046_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	046	1	1	01	01	H4513_046_1	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H4513	046	1	1	01	01	H4513_046_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	046	1	1	01	01	H4513_046_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											99.08	40	40	40				98.54	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	046	1	1	01	01	H4513_046_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											608.22	30						475.14	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	046	2	1	01	01	H4513_046_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	046	2	1	01	01	H4513_046_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	046	2	1	01	01	H4513_046_2	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	0.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	0.00	20.00		20.00
H4513	046	2	1	01	01	H4513_046_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	046	2	1	01	01	H4513_046_2	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											99.08	40	40	40				98.54	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	046	2	1	01	01	H4513_046_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											608.22	30						475.14	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	047	0	1	01	01	H4513_047_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	047	0	1	01	01	H4513_047_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	047	0	1	01	01	H4513_047_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	047	0	1	01	01	H4513_047_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	047	0	1	01	01	H4513_047_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	047	0	1	01	01	H4513_047_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											699.21	33						479.04	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	048	0	1	01	01	H4513_048_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	048	0	1	01	01	H4513_048_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	048	0	1	01	01	H4513_048_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	048	0	1	01	01	H4513_048_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	048	0	1	01	01	H4513_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	048	0	1	01	01	H4513_048_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											588.12	33						412.97	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	049	1	1	01	01	H4513_049_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	049	1	1	01	01	H4513_049_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	049	1	1	01	01	H4513_049_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4513	049	1	1	01	01	H4513_049_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	1	1	01	01	H4513_049_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	1	1	01	01	H4513_049_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.93	33						515.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	049	2	1	01	01	H4513_049_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	049	2	1	01	01	H4513_049_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	049	2	1	01	01	H4513_049_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4513	049	2	1	01	01	H4513_049_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	2	1	01	01	H4513_049_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	2	1	01	01	H4513_049_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.93	33						515.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	049	3	1	01	01	H4513_049_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	049	3	1	01	01	H4513_049_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	049	3	1	01	01	H4513_049_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4513	049	3	1	01	01	H4513_049_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	3	1	01	01	H4513_049_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	3	1	01	01	H4513_049_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.93	33						515.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	049	4	1	01	01	H4513_049_4	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	049	4	1	01	01	H4513_049_4	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	049	4	1	01	01	H4513_049_4	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4513	049	4	1	01	01	H4513_049_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	4	1	01	01	H4513_049_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	4	1	01	01	H4513_049_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.93	33						515.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	049	5	1	01	01	H4513_049_5	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	049	5	1	01	01	H4513_049_5	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	049	5	1	01	01	H4513_049_5	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H4513	049	5	1	01	01	H4513_049_5	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	5	1	01	01	H4513_049_5	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	049	5	1	01	01	H4513_049_5	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.93	33						515.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	050	0	1	01	01	H4513_050_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	050	0	1	01	01	H4513_050_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	050	0	1	01	01	H4513_050_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	050	0	1	01	01	H4513_050_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	050	0	1	01	01	H4513_050_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	050	0	1	01	01	H4513_050_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											664.01	33						479.27	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	051	0	1	01	01	H4513_051_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	051	0	1	01	01	H4513_051_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	051	0	1	01	01	H4513_051_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	051	0	1	01	01	H4513_051_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	051	0	1	01	01	H4513_051_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	051	0	1	01	01	H4513_051_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											687.95	33						505.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	052	0	1	01	01	H4513_052_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	052	0	1	01	01	H4513_052_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	052	0	1	01	01	H4513_052_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	052	0	1	01	01	H4513_052_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	052	0	1	01	01	H4513_052_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	052	0	1	01	01	H4513_052_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											740.50	33						397.11	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	059	0	1	01	01	H4513_059_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	059	0	1	01	01	H4513_059_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	059	0	1	01	01	H4513_059_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	059	0	1	01	01	H4513_059_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	059	0	1	01	01	H4513_059_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	059	0	1	01	01	H4513_059_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											803.47	33						583.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	061	1	1	01	01	H4513_061_1	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	061	1	1	01	01	H4513_061_1	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	061	1	1	01	01	H4513_061_1	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	061	1	1	01	01	H4513_061_1	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	1	1	01	01	H4513_061_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	1	1	01	01	H4513_061_1	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											718.90	33						472.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	061	2	1	01	01	H4513_061_2	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	061	2	1	01	01	H4513_061_2	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	061	2	1	01	01	H4513_061_2	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	061	2	1	01	01	H4513_061_2	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	2	1	01	01	H4513_061_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	2	1	01	01	H4513_061_2	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											718.90	33						472.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	061	3	1	01	01	H4513_061_3	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	061	3	1	01	01	H4513_061_3	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	061	3	1	01	01	H4513_061_3	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	061	3	1	01	01	H4513_061_3	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	3	1	01	01	H4513_061_3	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	3	1	01	01	H4513_061_3	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											718.90	33						472.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	061	4	1	01	01	H4513_061_4	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	061	4	1	01	01	H4513_061_4	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	061	4	1	01	01	H4513_061_4	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	061	4	1	01	01	H4513_061_4	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	4	1	01	01	H4513_061_4	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	4	1	01	01	H4513_061_4	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											718.90	33						472.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	061	5	1	01	01	H4513_061_5	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	061	5	1	01	01	H4513_061_5	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	061	5	1	01	01	H4513_061_5	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	061	5	1	01	01	H4513_061_5	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	5	1	01	01	H4513_061_5	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	061	5	1	01	01	H4513_061_5	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											718.90	33						472.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	064	0	1	01	01	H4513_064_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	064	0	1	01	01	H4513_064_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	064	0	1	01	01	H4513_064_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	064	0	1	01	01	H4513_064_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	064	0	1	01	01	H4513_064_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	064	0	1	01	01	H4513_064_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											610.65	33						484.39	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	068	1	1	01	01	H4513_068_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	068	1	1	01	01	H4513_068_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	068	1	1	01	01	H4513_068_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	068	1	1	01	01	H4513_068_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	068	1	1	01	01	H4513_068_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	068	1	1	01	01	H4513_068_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											642.57	30						486.53	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	068	2	1	01	01	H4513_068_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	068	2	1	01	01	H4513_068_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	068	2	1	01	01	H4513_068_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	068	2	1	01	01	H4513_068_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	068	2	1	01	01	H4513_068_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	068	2	1	01	01	H4513_068_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											642.57	30						486.53	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	068	3	1	01	01	H4513_068_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	068	3	1	01	01	H4513_068_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	068	3	1	01	01	H4513_068_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H4513	068	3	1	01	01	H4513_068_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	068	3	1	01	01	H4513_068_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	068	3	1	01	01	H4513_068_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											642.57	30						486.53	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	073	0	1	01	01	H4513_073_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	073	0	1	01	01	H4513_073_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	073	0	1	01	01	H4513_073_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	073	0	1	01	01	H4513_073_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	073	0	1	01	01	H4513_073_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	073	0	1	01	01	H4513_073_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											773.46	33						538.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	074	0	1	01	01	H4513_074_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	074	0	1	01	01	H4513_074_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	074	0	1	01	01	H4513_074_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	074	0	1	01	01	H4513_074_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	074	0	1	01	01	H4513_074_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	074	0	1	01	01	H4513_074_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											750.49	33						465.94	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	076	1	1	01	01	H4513_076_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	076	1	1	01	01	H4513_076_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	076	1	1	01	01	H4513_076_1	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4513	076	1	1	01	01	H4513_076_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	076	1	1	01	01	H4513_076_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	076	1	1	01	01	H4513_076_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											550.29	33						365.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	076	2	1	01	01	H4513_076_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	076	2	1	01	01	H4513_076_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	076	2	1	01	01	H4513_076_2	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4513	076	2	1	01	01	H4513_076_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	076	2	1	01	01	H4513_076_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	076	2	1	01	01	H4513_076_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											550.29	33						365.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	077	1	1	01	01	H4513_077_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	077	1	1	01	01	H4513_077_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	077	1	1	01	01	H4513_077_1	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4513	077	1	1	01	01	H4513_077_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	077	1	1	01	01	H4513_077_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	077	1	1	01	01	H4513_077_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											791.37	33						496.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	077	2	1	01	01	H4513_077_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	077	2	1	01	01	H4513_077_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	077	2	1	01	01	H4513_077_2	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4513	077	2	1	01	01	H4513_077_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	077	2	1	01	01	H4513_077_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	077	2	1	01	01	H4513_077_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											791.37	33						496.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	077	3	1	01	01	H4513_077_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	077	3	1	01	01	H4513_077_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	077	3	1	01	01	H4513_077_3	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4513	077	3	1	01	01	H4513_077_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	077	3	1	01	01	H4513_077_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	077	3	1	01	01	H4513_077_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											791.37	33						496.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	1	1	01	01	H4513_083_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	1	1	01	01	H4513_083_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	1	1	01	01	H4513_083_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	1	1	01	01	H4513_083_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	1	1	01	01	H4513_083_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	1	1	01	01	H4513_083_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	2	1	01	01	H4513_083_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	2	1	01	01	H4513_083_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	2	1	01	01	H4513_083_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	2	1	01	01	H4513_083_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	2	1	01	01	H4513_083_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	2	1	01	01	H4513_083_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	3	1	01	01	H4513_083_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	3	1	01	01	H4513_083_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	3	1	01	01	H4513_083_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	3	1	01	01	H4513_083_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	3	1	01	01	H4513_083_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	3	1	01	01	H4513_083_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	4	1	01	01	H4513_083_4	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	4	1	01	01	H4513_083_4	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	4	1	01	01	H4513_083_4	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	4	1	01	01	H4513_083_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	4	1	01	01	H4513_083_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	4	1	01	01	H4513_083_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	5	1	01	01	H4513_083_5	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	5	1	01	01	H4513_083_5	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	5	1	01	01	H4513_083_5	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	5	1	01	01	H4513_083_5	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	5	1	01	01	H4513_083_5	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	5	1	01	01	H4513_083_5	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	6	1	01	01	H4513_083_6	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	6	1	01	01	H4513_083_6	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	6	1	01	01	H4513_083_6	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	6	1	01	01	H4513_083_6	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	6	1	01	01	H4513_083_6	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	6	1	01	01	H4513_083_6	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	083	7	1	01	01	H4513_083_7	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H4513	083	7	1	01	01	H4513_083_7	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4513	083	7	1	01	01	H4513_083_7	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H4513	083	7	1	01	01	H4513_083_7	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	7	1	01	01	H4513_083_7	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	083	7	1	01	01	H4513_083_7	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											752.76	33						530.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	084	0	1	02	01	H4513_084_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	084	0	1	02	01	H4513_084_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	084	0	1	02	01	H4513_084_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H4513	084	0	1	02	01	H4513_084_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	084	0	1	02	01	H4513_084_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	084	0	1	02	01	H4513_084_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											768.36	33						687.50	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	085	0	1	01	01	H4513_085_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	085	0	1	01	01	H4513_085_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	085	0	1	01	01	H4513_085_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H4513	085	0	1	01	01	H4513_085_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	085	0	1	01	01	H4513_085_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	085	0	1	01	01	H4513_085_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											601.53	33						506.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4513	086	0	1	01	01	H4513_086_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H4513	086	0	1	01	01	H4513_086_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4513	086	0	1	01	01	H4513_086_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H4513	086	0	1	01	01	H4513_086_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	086	0	1	01	01	H4513_086_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4513	086	0	1	01	01	H4513_086_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											605.65	33						493.32	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4514	007	0	1	02	01	H4514_007_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	007	0	1	02	01	H4514_007_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4514	007	0	1	02	01	H4514_007_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	007	0	1	02	01	H4514_007_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4514	007	0	1	02	01	H4514_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	007	0	1	02	01	H4514_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	007	0	1	02	01	H4514_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				523.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	014	0	1	02	01	H4514_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	014	0	1	02	01	H4514_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4514	014	0	1	02	01	H4514_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	014	0	1	02	01	H4514_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4514	014	0	1	02	01	H4514_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	014	0	1	02	01	H4514_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	014	0	1	02	01	H4514_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				482.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	015	0	1	02	01	H4514_015_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	015	0	1	02	01	H4514_015_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4514	015	0	1	02	01	H4514_015_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	015	0	1	02	01	H4514_015_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4514	015	0	1	02	01	H4514_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H4514	015	0	1	02	01	H4514_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	015	0	1	02	01	H4514_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				426.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	017	0	1	02	01	H4514_017_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	017	0	1	02	01	H4514_017_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4514	017	0	1	02	01	H4514_017_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4514	017	0	1	02	01	H4514_017_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4514	017	0	1	02	01	H4514_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	017	0	1	02	01	H4514_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4514	017	0	1	02	01	H4514_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				613.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	001	0	1	01	01	H4523_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	001	0	1	01	01	H4523_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	001	0	1	01	01	H4523_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	001	0	1	01	01	H4523_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	001	0	1	01	01	H4523_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4523	001	0	1	01	01	H4523_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	001	0	1	01	01	H4523_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											856.55	28						625.91	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4523	015	0	1	01	01	H4523_015_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	015	0	1	01	01	H4523_015_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	015	0	1	01	01	H4523_015_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	015	0	1	01	01	H4523_015_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	015	0	1	01	01	H4523_015_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4523	015	0	1	01	01	H4523_015_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	015	0	1	01	01	H4523_015_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											831.24	30						612.17	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4523	020	0	1	01	01	H4523_020_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	020	0	1	01	01	H4523_020_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	020	0	1	01	01	H4523_020_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	020	0	1	01	01	H4523_020_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	020	0	1	01	01	H4523_020_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4523	020	0	1	01	01	H4523_020_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	020	0	1	01	01	H4523_020_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.96	30						604.76	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4523	021	0	1	01	01	H4523_021_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	021	0	1	01	01	H4523_021_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	021	0	1	01	01	H4523_021_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	021	0	1	01	01	H4523_021_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	021	0	1	01	01	H4523_021_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4523	021	0	1	01	01	H4523_021_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	021	0	1	01	01	H4523_021_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											809.88	30						646.22	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4523	024	0	1	01	01	H4523_024_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	024	0	1	01	01	H4523_024_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	024	0	1	01	01	H4523_024_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	024	0	1	01	01	H4523_024_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4523	024	0	1	01	01	H4523_024_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4523	024	0	1	01	01	H4523_024_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4523	024	0	1	01	01	H4523_024_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											880.35	33						583.94	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4527	001	0	1	02	01	H4527_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	001	0	1	02	01	H4527_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	001	0	1	02	01	H4527_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	001	0	1	02	01	H4527_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	001	0	1	02	01	H4527_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	001	0	1	02	01	H4527_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	001	0	1	02	01	H4527_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				546.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	002	0	1	02	01	H4527_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	002	0	1	02	01	H4527_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	002	0	1	02	01	H4527_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	002	0	1	02	01	H4527_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	002	0	1	02	01	H4527_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	002	0	1	02	01	H4527_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	002	0	1	02	01	H4527_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				596.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	005	0	1	02	01	H4527_005_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	005	0	1	02	01	H4527_005_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	005	0	1	02	01	H4527_005_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	005	0	1	02	01	H4527_005_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	005	0	1	02	01	H4527_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	005	0	1	02	01	H4527_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	005	0	1	02	01	H4527_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				669.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	013	0	1	02	01	H4527_013_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	013	0	1	02	01	H4527_013_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	013	0	1	02	01	H4527_013_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	013	0	1	02	01	H4527_013_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	013	0	1	02	01	H4527_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	013	0	1	02	01	H4527_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	013	0	1	02	01	H4527_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				553.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	015	0	1	02	01	H4527_015_0	4		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				1.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	015	0	1	02	01	H4527_015_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				3.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	015	0	1	02	01	H4527_015_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				72.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H4527	015	0	1	02	01	H4527_015_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H4527	015	0	1	02	01	H4527_015_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				329.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	037	0	1	02	01	H4527_037_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	037	0	1	02	01	H4527_037_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	037	0	1	02	01	H4527_037_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	037	0	1	02	01	H4527_037_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	037	0	1	02	01	H4527_037_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	037	0	1	02	01	H4527_037_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	037	0	1	02	01	H4527_037_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				569.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	039	0	1	02	01	H4527_039_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	039	0	1	02	01	H4527_039_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	039	0	1	02	01	H4527_039_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	039	0	1	02	01	H4527_039_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	039	0	1	02	01	H4527_039_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H4527	039	0	1	02	01	H4527_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	039	0	1	02	01	H4527_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				586.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	040	0	1	02	01	H4527_040_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	040	0	1	02	01	H4527_040_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	040	0	1	02	01	H4527_040_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	040	0	1	02	01	H4527_040_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	040	0	1	02	01	H4527_040_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H4527	040	0	1	02	01	H4527_040_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	040	0	1	02	01	H4527_040_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				585.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	041	0	1	02	01	H4527_041_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	041	0	1	02	01	H4527_041_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	041	0	1	02	01	H4527_041_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	041	0	1	02	01	H4527_041_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	041	0	1	02	01	H4527_041_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H4527	041	0	1	02	01	H4527_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	041	0	1	02	01	H4527_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				532.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	042	0	1	02	01	H4527_042_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	042	0	1	02	01	H4527_042_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	042	0	1	02	01	H4527_042_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	042	0	1	02	01	H4527_042_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	042	0	1	02	01	H4527_042_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H4527	042	0	1	02	01	H4527_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	042	0	1	02	01	H4527_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				469.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	045	0	1	02	01	H4527_045_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	045	0	1	02	01	H4527_045_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	045	0	1	02	01	H4527_045_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	045	0	1	02	01	H4527_045_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	045	0	1	02	01	H4527_045_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	045	0	1	02	01	H4527_045_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	045	0	1	02	01	H4527_045_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				591.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	048	0	1	02	01	H4527_048_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	048	0	1	02	01	H4527_048_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	048	0	1	02	01	H4527_048_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	048	0	1	02	01	H4527_048_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	048	0	1	02	01	H4527_048_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	048	0	1	02	01	H4527_048_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	048	0	1	02	01	H4527_048_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				331.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	051	0	1	02	01	H4527_051_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	051	0	1	02	01	H4527_051_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4527	051	0	1	02	01	H4527_051_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4527	051	0	1	02	01	H4527_051_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4527	051	0	1	02	01	H4527_051_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	051	0	1	02	01	H4527_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4527	051	0	1	02	01	H4527_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				312.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4537	001	0	1	04	01	H4537_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	001	0	1	04	01	H4537_001_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4537	001	0	1	04	01	H4537_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	001	0	1	04	01	H4537_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4537	001	0	1	04	01	H4537_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											96.10	50	50	50				96.10	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4537	001	0	1	04	01	H4537_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4537	001	0	1	04	01	H4537_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	001	0	1	04	01	H4537_001_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4537	002	0	1	04	01	H4537_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	002	0	1	04	01	H4537_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	002	0	1	04	01	H4537_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4537	002	0	1	04	01	H4537_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.26	50	50	50				97.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4537	002	0	1	04	01	H4537_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4537	002	0	1	04	01	H4537_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	003	0	1	04	01	H4537_003_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	003	0	1	04	01	H4537_003_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H4537	003	0	1	04	01	H4537_003_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					1.00	2.00	3.00											3.00	6.00	9.00				1.00	2.00	0.00				3.00				3.00			0.10	0.03		0.10	0.03	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	003	0	1	04	01	H4537_003_0	18			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					1.00	2.00	3.00											3.00	6.00	9.00				1.00	2.00	0.00				3.00				3.00			0.10	0.03		0.10	0.03	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4537	003	0	1	04	01	H4537_003_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4537	003	0	1	04	01	H4537_003_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.24	50	50	50				92.24	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4537	003	0	1	04	01	H4537_003_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4537	003	0	1	04	01	H4537_003_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4537	003	0	1	04	01	H4537_003_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4544	001	0	1	04	01	H4544_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4544	001	0	1	04	01	H4544_001_0	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4544	001	0	1	04	01	H4544_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4544	001	0	1	04	01	H4544_001_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4544	001	0	1	04	01	H4544_001_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						135.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H4544	001	0	1	04	01	H4544_001_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						300.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			105.00	35.00		35.00
H4544	001	0	1	04	01	H4544_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				638.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	003	0	1	02	01	H4604_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	003	0	1	02	01	H4604_003_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	003	0	1	02	01	H4604_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	003	0	1	02	01	H4604_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	003	0	1	02	01	H4604_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	003	0	1	02	01	H4604_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	003	0	1	02	01	H4604_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				460.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	011	0	1	02	01	H4604_011_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	011	0	1	02	01	H4604_011_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	011	0	1	02	01	H4604_011_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	011	0	1	02	01	H4604_011_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	011	0	1	02	01	H4604_011_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	011	0	1	02	01	H4604_011_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	011	0	1	02	01	H4604_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				465.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	012	0	1	02	01	H4604_012_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	012	0	1	02	01	H4604_012_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	012	0	1	02	01	H4604_012_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	012	0	1	02	01	H4604_012_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	012	0	1	02	01	H4604_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	012	0	1	02	01	H4604_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	012	0	1	02	01	H4604_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				626.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	013	0	1	02	01	H4604_013_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	013	0	1	02	01	H4604_013_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	013	0	1	02	01	H4604_013_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	013	0	1	02	01	H4604_013_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	013	0	1	02	01	H4604_013_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	013	0	1	02	01	H4604_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	013	0	1	02	01	H4604_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				493.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	014	0	1	02	01	H4604_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	014	0	1	02	01	H4604_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	014	0	1	02	01	H4604_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	6.00		18.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	014	0	1	02	01	H4604_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	6.00		18.00																											18.00						0.00				6.00				6.00		0.20						0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	014	0	1	02	01	H4604_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	014	0	1	02	01	H4604_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	014	0	1	02	01	H4604_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				295.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	015	0	1	02	01	H4604_015_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	015	0	1	02	01	H4604_015_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	015	0	1	02	01	H4604_015_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	7.00		21.00																											21.00						0.00				7.00				7.00		0.23						0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	015	0	1	02	01	H4604_015_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	7.00		21.00																											21.00						0.00				7.00				7.00		0.23						0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	015	0	1	02	01	H4604_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	015	0	1	02	01	H4604_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	015	0	1	02	01	H4604_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				554.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	016	0	1	02	01	H4604_016_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	016	0	1	02	01	H4604_016_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	016	0	1	02	01	H4604_016_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	016	0	1	02	01	H4604_016_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	016	0	1	02	01	H4604_016_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	016	0	1	02	01	H4604_016_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	016	0	1	02	01	H4604_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				449.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	017	0	1	02	01	H4604_017_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	017	0	1	02	01	H4604_017_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	017	0	1	02	01	H4604_017_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	017	0	1	02	01	H4604_017_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	017	0	1	02	01	H4604_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H4604	017	0	1	02	01	H4604_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	017	0	1	02	01	H4604_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				328.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	018	0	1	02	01	H4604_018_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	018	0	1	02	01	H4604_018_0	5			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	018	0	1	02	01	H4604_018_0	5			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	018	0	1	02	01	H4604_018_0	5			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	018	0	1	02	01	H4604_018_0	5			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H4604	018	0	1	02	01	H4604_018_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H4604	018	0	1	02	01	H4604_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											534.00	33						486.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	020	0	1	02	01	H4604_020_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	020	0	1	02	01	H4604_020_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	020	0	1	02	01	H4604_020_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	020	0	1	02	01	H4604_020_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	020	0	1	02	01	H4604_020_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	020	0	1	02	01	H4604_020_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	020	0	1	02	01	H4604_020_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				578.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	022	0	1	02	01	H4604_022_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	022	0	1	02	01	H4604_022_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4604	022	0	1	02	01	H4604_022_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4604	022	0	1	02	01	H4604_022_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H4604	022	0	1	02	01	H4604_022_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	022	0	1	02	01	H4604_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H4604	022	0	1	02	01	H4604_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				437.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4605	002	0	1	04	01	H4605_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H4605	002	0	1	04	01	H4605_002_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H4605	002	0	1	04	01	H4605_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H4605	002	0	1	04	01	H4605_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4605	002	0	1	04	01	H4605_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1149.44	31						1149.44	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4605	004	0	1	04	01	H4605_004_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H4605	004	0	1	04	01	H4605_004_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H4605	004	0	1	04	01	H4605_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H4605	004	0	1	04	01	H4605_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H4605	004	0	1	04	01	H4605_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4620	001	0	1	04	01	H4620_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H4620	001	0	1	04	01	H4620_001_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H4620	001	0	1	04	01	H4620_001_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H4620	001	0	1	04	01	H4620_001_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H4620	001	0	1	04	01	H4620_001_0	5			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H4620	001	0	1	04	01	H4620_001_0	5			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H4620	001	0	1	04	01	H4620_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H4623	001	0	1	02	01	H4623_001_0	12			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4623	001	0	1	02	01	H4623_001_0	12			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4623	001	0	1	02	01	H4623_001_0	12			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4623	001	0	1	02	01	H4623_001_0	12			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4623	001	0	1	02	01	H4623_001_0	12			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4623	001	0	1	02	01	H4623_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4623	001	0	1	02	01	H4623_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4623	002	0	1	02	01	H4623_002_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H4623	002	0	1	02	01	H4623_002_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4623	002	0	1	02	01	H4623_002_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H4623	002	0	1	02	01	H4623_002_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4623	002	0	1	02	01	H4623_002_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4623	002	0	1	02	01	H4623_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H4623	002	0	1	02	01	H4623_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H4624	001	0	1	01	01	H4624_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	001	0	1	01	01	H4624_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4624	001	0	1	01	01	H4624_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	001	0	1	01	01	H4624_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	001	0	1	01	01	H4624_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	001	0	1	01	01	H4624_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	003	0	1	01	01	H4624_003_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	003	0	1	01	01	H4624_003_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4624	003	0	1	01	01	H4624_003_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	003	0	1	01	01	H4624_003_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	003	0	1	01	01	H4624_003_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	003	0	1	01	01	H4624_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	006	0	1	01	01	H4624_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	006	0	1	01	01	H4624_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4624	006	0	1	01	01	H4624_006_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	006	0	1	01	01	H4624_006_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	006	0	1	01	01	H4624_006_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	006	0	1	01	01	H4624_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	010	0	1	01	01	H4624_010_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	010	0	1	01	01	H4624_010_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4624	010	0	1	01	01	H4624_010_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	010	0	1	01	01	H4624_010_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	010	0	1	01	01	H4624_010_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	010	0	1	01	01	H4624_010_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	010	0	1	01	01	H4624_010_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	011	0	1	01	01	H4624_011_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	011	0	1	01	01	H4624_011_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4624	011	0	1	01	01	H4624_011_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	011	0	1	01	01	H4624_011_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	011	0	1	01	01	H4624_011_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	011	0	1	01	01	H4624_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	011	0	1	01	01	H4624_011_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	012	0	1	01	01	H4624_012_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	012	0	1	01	01	H4624_012_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4624	012	0	1	01	01	H4624_012_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	012	0	1	01	01	H4624_012_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	012	0	1	01	01	H4624_012_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	012	0	1	01	01	H4624_012_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	012	0	1	01	01	H4624_012_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	016	0	1	01	01	H4624_016_0	10		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	016	0	1	01	01	H4624_016_0	10		N	Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				19.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	016	0	1	01	01	H4624_016_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				121.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	016	0	1	01	01	H4624_016_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				91.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	016	0	1	01	01	H4624_016_0	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	019	0	1	01	01	H4624_019_0	11		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	019	0	1	01	01	H4624_019_0	11		N	Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				19.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	019	0	1	01	01	H4624_019_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				121.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	019	0	1	01	01	H4624_019_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				91.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	019	0	1	01	01	H4624_019_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	022	0	1	01	01	H4624_022_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	022	0	1	01	01	H4624_022_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4624	022	0	1	01	01	H4624_022_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	022	0	1	01	01	H4624_022_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	022	0	1	01	01	H4624_022_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	022	0	1	01	01	H4624_022_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	023	0	1	01	01	H4624_023_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	023	0	1	01	01	H4624_023_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4624	023	0	1	01	01	H4624_023_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	023	0	1	01	01	H4624_023_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	023	0	1	01	01	H4624_023_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	023	0	1	01	01	H4624_023_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	023	0	1	01	01	H4624_023_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	024	0	1	01	01	H4624_024_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	024	0	1	01	01	H4624_024_0	10			Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	024	0	1	01	01	H4624_024_0	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	024	0	1	01	01	H4624_024_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	024	0	1	01	01	H4624_024_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	024	0	1	01	01	H4624_024_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	025	0	1	01	01	H4624_025_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	025	0	1	01	01	H4624_025_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4624	025	0	1	01	01	H4624_025_0	12			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	025	0	1	01	01	H4624_025_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	025	0	1	01	01	H4624_025_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	025	0	1	01	01	H4624_025_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	025	0	1	01	01	H4624_025_0	12			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	026	0	1	01	01	H4624_026_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	026	0	1	01	01	H4624_026_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4624	026	0	1	01	01	H4624_026_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	026	0	1	01	01	H4624_026_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	026	0	1	01	01	H4624_026_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	026	0	1	01	01	H4624_026_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4624	027	0	1	01	01	H4624_027_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	027	0	1	01	01	H4624_027_0	9			Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	027	0	1	01	01	H4624_027_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	027	0	1	01	01	H4624_027_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	027	0	1	01	01	H4624_027_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	027	0	1	01	01	H4624_027_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	028	0	1	01	01	H4624_028_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4624	028	0	1	01	01	H4624_028_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4624	028	0	1	01	01	H4624_028_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	028	0	1	01	01	H4624_028_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	028	0	1	01	01	H4624_028_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	028	0	1	01	01	H4624_028_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4624	028	0	1	01	01	H4624_028_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4661	001	0	1	02	01	H4661_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4661	001	0	1	02	01	H4661_001_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4661	001	0	1	02	01	H4661_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4661	001	0	1	02	01	H4661_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.55	50	50	50				85.55	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4661	001	0	1	02	01	H4661_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4661	001	0	1	02	01	H4661_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4676	001	0	1	01	01	H4676_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01			1				30	60	90	2	1							30		31								10.00	20.00	30.00					0.00	0.00	0.00																							10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00							0.00		0.00
H4676	001	0	1	01	01	H4676_001_0	6			Preferred Generic	4	11	1	2	1	3		111	01			1				30	60	90	2	1							30		31								10.00	20.00	30.00					0.00	0.00	0.00																							10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H4676	001	0	1	01	01	H4676_001_0	6			Generic	4	11	1	2	2	1		111	01			1				30	60	90	2	1							30		31								20.00	40.00	60.00					5.00	10.00	15.00																							20.00				20.00			0.67	0.17				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)																											
H4676	001	0	1	01	01	H4676_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01			1				30	60	90	2	1							30		31								40.00	80.00	120.00					25.00	50.00	75.00																							40.00				40.00			1.33	0.83				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	25.00	50.00	75.00							25.00		25.00
H4676	001	0	1	01	01	H4676_001_0	6			Non-Preferred Brand	4	11	1	2	4	1		111	01			1				30	60	90	2	1							30		31								100.00	200.00	300.00					100.00	200.00	300.00																							100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)																											
H4676	001	0	1	01	01	H4676_001_0	6			Specialty Tier	4	11	1	1	5	1		111	01			1				30	60	90	2	1							30		31											1400.03	33	33	33				890.90	33	33	33																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)																											
H4676	001	0	1	01	01	H4676_001_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	01			1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)																											
H4676	001	0	1	01	01	H4676_001_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	01			1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H4699	001	0	1	04	01	H4699_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4699	001	0	1	04	01	H4699_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4699	001	0	1	04	01	H4699_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4699	001	0	1	04	01	H4699_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.73	47	47	47				99.73	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4699	001	0	1	04	01	H4699_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4699	001	0	1	04	01	H4699_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4699	001	0	1	04	01	H4699_001_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4711	001	0	1	02	01	H4711_001_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	001	0	1	02	01	H4711_001_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	001	0	1	02	01	H4711_001_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	001	0	1	02	01	H4711_001_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	001	0	1	02	01	H4711_001_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	001	0	1	02	01	H4711_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	001	0	1	02	01	H4711_001_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											931.66	33						662.01	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4711	002	0	1	02	01	H4711_002_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	002	0	1	02	01	H4711_002_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	002	0	1	02	01	H4711_002_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	002	0	1	02	01	H4711_002_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	002	0	1	02	01	H4711_002_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	002	0	1	02	01	H4711_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	002	0	1	02	01	H4711_002_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											983.27	33						716.00	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4711	005	0	1	02	01	H4711_005_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	005	0	1	02	01	H4711_005_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	005	0	1	02	01	H4711_005_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	005	0	1	02	01	H4711_005_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	005	0	1	02	01	H4711_005_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	005	0	1	02	01	H4711_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	005	0	1	02	01	H4711_005_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											869.69	33						654.21	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4711	006	0	1	02	01	H4711_006_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	006	0	1	02	01	H4711_006_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	006	0	1	02	01	H4711_006_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	006	0	1	02	01	H4711_006_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	006	0	1	02	01	H4711_006_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.60	25	25	25				95.24	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	006	0	1	02	01	H4711_006_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.31	50	50	50				49.03	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	006	0	1	02	01	H4711_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											700.94	29						584.67	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4711	007	0	1	02	01	H4711_007_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	007	0	1	02	01	H4711_007_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	007	0	1	02	01	H4711_007_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	007	0	1	02	01	H4711_007_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	007	0	1	02	01	H4711_007_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.09	25	25	25				93.03	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	007	0	1	02	01	H4711_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.53	50	50	50				47.54	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	007	0	1	02	01	H4711_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											741.67	29						589.90	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4711	008	0	1	02	01	H4711_008_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	008	0	1	02	01	H4711_008_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	008	0	1	02	01	H4711_008_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	008	0	1	02	01	H4711_008_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	008	0	1	02	01	H4711_008_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.97	25	25	25				92.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	008	0	1	02	01	H4711_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.86	50	50	50				50.85	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	008	0	1	02	01	H4711_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											684.59	29						555.48	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4711	009	0	1	02	01	H4711_009_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	009	0	1	02	01	H4711_009_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	009	0	1	02	01	H4711_009_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	009	0	1	02	01	H4711_009_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4711	009	0	1	02	01	H4711_009_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.55	25	25	25				91.09	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4711	009	0	1	02	01	H4711_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.36	50	50	50				49.54	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4711	009	0	1	02	01	H4711_009_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											743.99	29						574.47	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4754	004	0	1	04	01	H4754_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	004	0	1	04	01	H4754_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	004	0	1	04	01	H4754_004_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H4754	004	0	1	04	01	H4754_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.80	33	33	33				73.55	31	31	31										33	33	33				31	31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	004	0	1	04	01	H4754_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											132.47	33						120.57	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4754	004	0	1	04	01	H4754_004_0	6			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	004	0	1	04	01	H4754_004_0	6			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4754	011	0	1	04	01	H4754_011_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	011	0	1	04	01	H4754_011_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					4.00	8.00	12.00											17.00	34.00	51.00				4.00	8.00	8.00				17.00				17.00			0.57	0.13		0.57	0.13	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	011	0	1	04	01	H4754_011_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H4754	011	0	1	04	01	H4754_011_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.71	30	30	30				65.15	29	29	29										30	30	30				29	29	29			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	011	0	1	04	01	H4754_011_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											219.34	30						191.48	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4754	011	0	1	04	01	H4754_011_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	011	0	1	04	01	H4754_011_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4754	017	0	1	04	01	H4754_017_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.10		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	017	0	1	04	01	H4754_017_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	24.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	017	0	1	04	01	H4754_017_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H4754	017	0	1	04	01	H4754_017_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											63.58	32	32	32				73.21	31	31	31										32	32	32				31	31	31			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	017	0	1	04	01	H4754_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											239.48	29						194.15	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4754	017	0	1	04	01	H4754_017_0	5			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4754	017	0	1	04	01	H4754_017_0	5			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4801	002	0	1	04	01	H4801_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	002	0	1	04	01	H4801_002_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	002	0	1	04	01	H4801_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	002	0	1	04	01	H4801_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	002	0	1	04	01	H4801_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	007	0	1	04	01	H4801_007_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H4801	007	0	1	04	01	H4801_007_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4801	007	0	1	04	01	H4801_007_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H4801	007	0	1	04	01	H4801_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H4801	007	0	1	04	01	H4801_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	007	0	1	04	01	H4801_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	011	0	1	04	01	H4801_011_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	011	0	1	04	01	H4801_011_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	011	0	1	04	01	H4801_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	011	0	1	04	01	H4801_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	011	0	1	04	01	H4801_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	013	0	1	04	01	H4801_013_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	013	0	1	04	01	H4801_013_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	013	0	1	04	01	H4801_013_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	013	0	1	04	01	H4801_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	013	0	1	04	01	H4801_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	014	0	1	04	01	H4801_014_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	014	0	1	04	01	H4801_014_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	014	0	1	04	01	H4801_014_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	014	0	1	04	01	H4801_014_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	014	0	1	04	01	H4801_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	015	0	1	04	01	H4801_015_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	015	0	1	04	01	H4801_015_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	015	0	1	04	01	H4801_015_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	015	0	1	04	01	H4801_015_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	015	0	1	04	01	H4801_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	016	0	1	04	01	H4801_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	016	0	1	04	01	H4801_016_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	016	0	1	04	01	H4801_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	016	0	1	04	01	H4801_016_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	016	0	1	04	01	H4801_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	018	0	1	04	01	H4801_018_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	018	0	1	04	01	H4801_018_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	018	0	1	04	01	H4801_018_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	018	0	1	04	01	H4801_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	018	0	1	04	01	H4801_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	021	0	1	04	01	H4801_021_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	021	0	1	04	01	H4801_021_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	021	0	1	04	01	H4801_021_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	021	0	1	04	01	H4801_021_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	021	0	1	04	01	H4801_021_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4801	022	0	1	04	01	H4801_022_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H4801	022	0	1	04	01	H4801_022_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H4801	022	0	1	04	01	H4801_022_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	022	0	1	04	01	H4801_022_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4801	022	0	1	04	01	H4801_022_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4808	001	0	1	04	01	H4808_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4808	001	0	1	04	01	H4808_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H4808	001	0	1	04	01	H4808_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H4808	001	0	1	04	01	H4808_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H4808	001	0	1	04	01	H4808_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4808	001	0	1	04	01	H4808_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4808	001	0	1	04	01	H4808_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H4808	002	0	1	04	01	H4808_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4808	002	0	1	04	01	H4808_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H4808	002	0	1	04	01	H4808_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4808	002	0	1	04	01	H4808_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H4808	002	0	1	04	01	H4808_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4808	002	0	1	04	01	H4808_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4808	002	0	1	04	01	H4808_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H4808	003	0	1	04	01	H4808_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4808	003	0	1	04	01	H4808_003_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H4808	003	0	1	04	01	H4808_003_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H4808	003	0	1	04	01	H4808_003_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H4808	003	0	1	04	01	H4808_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4808	003	0	1	04	01	H4808_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4808	003	0	1	04	01	H4808_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H4835	001	0	1	02	01	H4835_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	001	0	1	02	01	H4835_001_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	001	0	1	02	01	H4835_001_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	001	0	1	02	01	H4835_001_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	001	0	1	02	01	H4835_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4835	001	0	1	02	01	H4835_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	001	0	1	02	01	H4835_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											828.91	33						610.76	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4835	002	0	1	02	01	H4835_002_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	002	0	1	02	01	H4835_002_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	002	0	1	02	01	H4835_002_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	002	0	1	02	01	H4835_002_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	002	0	1	02	01	H4835_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4835	002	0	1	02	01	H4835_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	002	0	1	02	01	H4835_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											891.02	33						593.15	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4835	003	0	1	02	01	H4835_003_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	003	0	1	02	01	H4835_003_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	003	0	1	02	01	H4835_003_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	003	0	1	02	01	H4835_003_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	003	0	1	02	01	H4835_003_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4835	003	0	1	02	01	H4835_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	003	0	1	02	01	H4835_003_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.93	33						654.95	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4835	004	0	1	02	01	H4835_004_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	004	0	1	02	01	H4835_004_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	004	0	1	02	01	H4835_004_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	004	0	1	02	01	H4835_004_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	004	0	1	02	01	H4835_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4835	004	0	1	02	01	H4835_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	004	0	1	02	01	H4835_004_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											925.61	33						663.15	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4835	005	0	1	02	01	H4835_005_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	005	0	1	02	01	H4835_005_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	005	0	1	02	01	H4835_005_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	005	0	1	02	01	H4835_005_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	005	0	1	02	01	H4835_005_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4835	005	0	1	02	01	H4835_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	005	0	1	02	01	H4835_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											902.07	33						646.83	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4835	006	0	1	02	01	H4835_006_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	006	0	1	02	01	H4835_006_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	006	0	1	02	01	H4835_006_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	006	0	1	02	01	H4835_006_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4835	006	0	1	02	01	H4835_006_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4835	006	0	1	02	01	H4835_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4835	006	0	1	02	01	H4835_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											757.29	28						572.44	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4847	001	0	1	01	01	H4847_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4847	001	0	1	01	01	H4847_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4847	001	0	1	01	01	H4847_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4847	001	0	1	01	01	H4847_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.16	49	49	49				99.16	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4847	001	0	1	01	01	H4847_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4847	001	0	1	01	01	H4847_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4847	001	0	1	01	01	H4847_001_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H4847	005	0	1	01	01	H4847_005_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4847	005	0	1	01	01	H4847_005_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4847	005	0	1	01	01	H4847_005_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H4847	005	0	1	01	01	H4847_005_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.66	49	49	49				99.66	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4847	005	0	1	01	01	H4847_005_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4847	005	0	1	01	01	H4847_005_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4863	001	0	1	01	01	H4863_001_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	001	0	1	01	01	H4863_001_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			0.00	0.00	0.00																7.00				7.00		0.23			0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	001	0	1	01	01	H4863_001_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4863	001	0	1	01	01	H4863_001_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4863	001	0	1	01	01	H4863_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1191.71	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	003	0	1	01	01	H4863_003_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	003	0	1	01	01	H4863_003_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	003	0	1	01	01	H4863_003_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4863	003	0	1	01	01	H4863_003_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4863	003	0	1	01	01	H4863_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1190.96	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	005	0	1	01	01	H4863_005_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	005	0	1	01	01	H4863_005_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4863	005	0	1	01	01	H4863_005_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4863	005	0	1	01	01	H4863_005_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4863	005	0	1	01	01	H4863_005_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1191.37	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4868	016	0	1	01	01	H4868_016_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4868	016	0	1	01	01	H4868_016_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4868	016	0	1	01	01	H4868_016_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H4868	016	0	1	01	01	H4868_016_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.84	45	45	45				99.84	45	45	45										45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4868	016	0	1	01	01	H4868_016_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4868	016	0	1	01	01	H4868_016_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4868	019	0	1	01	01	H4868_019_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4868	019	0	1	01	01	H4868_019_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4868	019	0	1	01	01	H4868_019_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H4868	019	0	1	01	01	H4868_019_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.59	47	47	47				98.59	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4868	019	0	1	01	01	H4868_019_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H4868	019	0	1	01	01	H4868_019_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4869	001	0	1	02	01	H4869_001_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	001	0	1	02	01	H4869_001_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	001	0	1	02	01	H4869_001_0	11			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	12.00				5.00	5.00	5.00				5.00		5.00
H4869	001	0	1	02	01	H4869_001_0	11			Generic	4	01	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	001	0	1	02	01	H4869_001_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	100.00				35.00	35.00	35.00				35.00		35.00
H4869	001	0	1	02	01	H4869_001_0	11			Preferred Brand	4	10	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										2																	
H4869	001	0	1	02	01	H4869_001_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	001	0	1	02	01	H4869_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1246.24	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	001	0	1	02	01	H4869_001_0	11			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4869	001	0	1	02	01	H4869_001_0	11			Select Diabetic Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	003	0	1	02	01	H4869_003_0	10			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	003	0	1	02	01	H4869_003_0	10			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	003	0	1	02	01	H4869_003_0	10			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	12.00				5.00	5.00	5.00				5.00		5.00
H4869	003	0	1	02	01	H4869_003_0	10			Generic	4	01	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	003	0	1	02	01	H4869_003_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	100.00				35.00	35.00	35.00				35.00		35.00
H4869	003	0	1	02	01	H4869_003_0	10			Preferred Brand	4	10	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										2																	
H4869	003	0	1	02	01	H4869_003_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	003	0	1	02	01	H4869_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1015.32	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	003	0	1	02	01	H4869_003_0	10			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4869	003	0	1	02	01	H4869_003_0	10			Select Diabetic Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	005	0	1	02	01	H4869_005_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	005	0	1	02	01	H4869_005_0	12			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	005	0	1	02	01	H4869_005_0	12			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													5.00	10.00	12.00				5.00	5.00	5.00				5.00		5.00
H4869	005	0	1	02	01	H4869_005_0	12			Generic	4	01	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	12.00																			5.00	5.00	5.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4869	005	0	1	02	01	H4869_005_0	12			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	100.00				35.00	35.00	35.00				35.00		35.00
H4869	005	0	1	02	01	H4869_005_0	12			Preferred Brand	4	10	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	100.00																			40.00	40.00	40.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										2																	
H4869	005	0	1	02	01	H4869_005_0	12			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	250.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	005	0	1	02	01	H4869_005_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1259.20	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H4869	005	0	1	02	01	H4869_005_0	12			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4869	005	0	1	02	01	H4869_005_0	12			Select Diabetic Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs										1																	
H4875	016	1	1	04	01	H4875_016_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	016	1	1	04	01	H4875_016_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	016	1	1	04	01	H4875_016_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	1	1	04	01	H4875_016_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											28.56	50	50	50				32.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	1	1	04	01	H4875_016_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	016	2	1	04	01	H4875_016_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	016	2	1	04	01	H4875_016_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	016	2	1	04	01	H4875_016_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	2	1	04	01	H4875_016_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											28.56	50	50	50				32.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	2	1	04	01	H4875_016_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	016	3	1	04	01	H4875_016_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	016	3	1	04	01	H4875_016_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	016	3	1	04	01	H4875_016_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	3	1	04	01	H4875_016_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											28.56	50	50	50				32.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	3	1	04	01	H4875_016_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	016	4	1	04	01	H4875_016_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	016	4	1	04	01	H4875_016_4	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	016	4	1	04	01	H4875_016_4	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	4	1	04	01	H4875_016_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											28.56	50	50	50				32.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	4	1	04	01	H4875_016_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	016	5	1	04	01	H4875_016_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	016	5	1	04	01	H4875_016_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	016	5	1	04	01	H4875_016_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	5	1	04	01	H4875_016_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											28.56	50	50	50				32.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	016	5	1	04	01	H4875_016_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	017	1	1	04	01	H4875_017_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	017	1	1	04	01	H4875_017_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	7.00	14.00	21.00	12.00	24.00	36.00	7.00	14.00	0.00	12.00		12.00
H4875	017	1	1	04	01	H4875_017_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								42.00	84.00	126.00					37.00	74.00	111.00											42.00	84.00	126.00				37.00	74.00	92.50				42.00				42.00			1.40	1.23		1.40	1.23	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	92.50	35.00		35.00
H4875	017	1	1	04	01	H4875_017_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.97	50	50	50				32.61	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	017	1	1	04	01	H4875_017_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	017	2	1	04	01	H4875_017_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	017	2	1	04	01	H4875_017_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	7.00	14.00	21.00	12.00	24.00	36.00	7.00	14.00	0.00	12.00		12.00
H4875	017	2	1	04	01	H4875_017_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								42.00	84.00	126.00					37.00	74.00	111.00											42.00	84.00	126.00				37.00	74.00	92.50				42.00				42.00			1.40	1.23		1.40	1.23	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	92.50	35.00		35.00
H4875	017	2	1	04	01	H4875_017_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.97	50	50	50				32.61	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	017	2	1	04	01	H4875_017_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	017	3	1	04	01	H4875_017_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	017	3	1	04	01	H4875_017_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	7.00	14.00	21.00	12.00	24.00	36.00	7.00	14.00	0.00	12.00		12.00
H4875	017	3	1	04	01	H4875_017_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								42.00	84.00	126.00					37.00	74.00	111.00											42.00	84.00	126.00				37.00	74.00	92.50				42.00				42.00			1.40	1.23		1.40	1.23	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	92.50	35.00		35.00
H4875	017	3	1	04	01	H4875_017_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.97	50	50	50				32.61	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	017	3	1	04	01	H4875_017_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	017	4	1	04	01	H4875_017_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	017	4	1	04	01	H4875_017_4	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	7.00	14.00	21.00	12.00	24.00	36.00	7.00	14.00	0.00	12.00		12.00
H4875	017	4	1	04	01	H4875_017_4	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								42.00	84.00	126.00					37.00	74.00	111.00											42.00	84.00	126.00				37.00	74.00	92.50				42.00				42.00			1.40	1.23		1.40	1.23	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	92.50	35.00		35.00
H4875	017	4	1	04	01	H4875_017_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.97	50	50	50				32.61	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	017	4	1	04	01	H4875_017_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	017	5	1	04	01	H4875_017_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	017	5	1	04	01	H4875_017_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	7.00	14.00	21.00	12.00	24.00	36.00	7.00	14.00	0.00	12.00		12.00
H4875	017	5	1	04	01	H4875_017_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								42.00	84.00	126.00					37.00	74.00	111.00											42.00	84.00	126.00				37.00	74.00	92.50				42.00				42.00			1.40	1.23		1.40	1.23	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	92.50	35.00		35.00
H4875	017	5	1	04	01	H4875_017_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.97	50	50	50				32.61	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	017	5	1	04	01	H4875_017_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	018	1	1	04	01	H4875_018_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					4.00	8.00	0.00											9.00	18.00	27.00				4.00	8.00	0.00				9.00				9.00			0.30	0.13		0.30	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	018	1	1	04	01	H4875_018_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					13.00	26.00	39.00											18.00	36.00	54.00				13.00	26.00	0.00				18.00				18.00			0.60	0.43		0.60	0.43	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	13.00	26.00	39.00	18.00	36.00	54.00	13.00	26.00	0.00	18.00		18.00
H4875	018	1	1	04	01	H4875_018_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	1	1	04	01	H4875_018_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.45	50	50	50				65.94	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	1	1	04	01	H4875_018_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	018	2	1	04	01	H4875_018_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					4.00	8.00	0.00											9.00	18.00	27.00				4.00	8.00	0.00				9.00				9.00			0.30	0.13		0.30	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	018	2	1	04	01	H4875_018_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					13.00	26.00	39.00											18.00	36.00	54.00				13.00	26.00	0.00				18.00				18.00			0.60	0.43		0.60	0.43	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	13.00	26.00	39.00	18.00	36.00	54.00	13.00	26.00	0.00	18.00		18.00
H4875	018	2	1	04	01	H4875_018_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	2	1	04	01	H4875_018_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.45	50	50	50				65.94	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	2	1	04	01	H4875_018_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	018	3	1	04	01	H4875_018_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					4.00	8.00	0.00											9.00	18.00	27.00				4.00	8.00	0.00				9.00				9.00			0.30	0.13		0.30	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	018	3	1	04	01	H4875_018_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					13.00	26.00	39.00											18.00	36.00	54.00				13.00	26.00	0.00				18.00				18.00			0.60	0.43		0.60	0.43	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	13.00	26.00	39.00	18.00	36.00	54.00	13.00	26.00	0.00	18.00		18.00
H4875	018	3	1	04	01	H4875_018_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	3	1	04	01	H4875_018_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.45	50	50	50				65.94	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	3	1	04	01	H4875_018_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	018	4	1	04	01	H4875_018_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					4.00	8.00	0.00											9.00	18.00	27.00				4.00	8.00	0.00				9.00				9.00			0.30	0.13		0.30	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	018	4	1	04	01	H4875_018_4	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					13.00	26.00	39.00											18.00	36.00	54.00				13.00	26.00	0.00				18.00				18.00			0.60	0.43		0.60	0.43	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	13.00	26.00	39.00	18.00	36.00	54.00	13.00	26.00	0.00	18.00		18.00
H4875	018	4	1	04	01	H4875_018_4	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	4	1	04	01	H4875_018_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.45	50	50	50				65.94	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	4	1	04	01	H4875_018_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	018	5	1	04	01	H4875_018_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					4.00	8.00	0.00											9.00	18.00	27.00				4.00	8.00	0.00				9.00				9.00			0.30	0.13		0.30	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	018	5	1	04	01	H4875_018_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					13.00	26.00	39.00											18.00	36.00	54.00				13.00	26.00	0.00				18.00				18.00			0.60	0.43		0.60	0.43	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	13.00	26.00	39.00	18.00	36.00	54.00	13.00	26.00	0.00	18.00		18.00
H4875	018	5	1	04	01	H4875_018_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	5	1	04	01	H4875_018_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.45	50	50	50				65.94	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	018	5	1	04	01	H4875_018_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	020	1	1	04	01	H4875_020_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	020	1	1	04	01	H4875_020_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					8.00	16.00	24.00											15.00	30.00	45.00				8.00	16.00	0.00				15.00				15.00			0.50	0.27		0.50	0.27	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	8.00	16.00	24.00	15.00	30.00	45.00	8.00	16.00	0.00	15.00		15.00
H4875	020	1	1	04	01	H4875_020_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					38.00	76.00	114.00											47.00	94.00	141.00				38.00	76.00	95.00				47.00				47.00			1.57	1.27		1.57	1.27	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H4875	020	1	1	04	01	H4875_020_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.99	45	45	45				26.05	40	40	40										45	45	45				40	40	40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	020	1	1	04	01	H4875_020_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	020	2	1	04	01	H4875_020_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	020	2	1	04	01	H4875_020_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					8.00	16.00	24.00											15.00	30.00	45.00				8.00	16.00	0.00				15.00				15.00			0.50	0.27		0.50	0.27	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	8.00	16.00	24.00	15.00	30.00	45.00	8.00	16.00	0.00	15.00		15.00
H4875	020	2	1	04	01	H4875_020_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					38.00	76.00	114.00											47.00	94.00	141.00				38.00	76.00	95.00				47.00				47.00			1.57	1.27		1.57	1.27	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H4875	020	2	1	04	01	H4875_020_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.99	45	45	45				26.05	40	40	40										45	45	45				40	40	40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	020	2	1	04	01	H4875_020_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	020	3	1	04	01	H4875_020_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	020	3	1	04	01	H4875_020_3	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					8.00	16.00	24.00											15.00	30.00	45.00				8.00	16.00	0.00				15.00				15.00			0.50	0.27		0.50	0.27	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	8.00	16.00	24.00	15.00	30.00	45.00	8.00	16.00	0.00	15.00		15.00
H4875	020	3	1	04	01	H4875_020_3	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					38.00	76.00	114.00											47.00	94.00	141.00				38.00	76.00	95.00				47.00				47.00			1.57	1.27		1.57	1.27	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00	35.00		35.00
H4875	020	3	1	04	01	H4875_020_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.99	45	45	45				26.05	40	40	40										45	45	45				40	40	40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	020	3	1	04	01	H4875_020_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	021	1	1	04	01	H4875_021_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					4.00	8.00	0.00											11.00	22.00	33.00				4.00	8.00	0.00				11.00				11.00			0.37	0.13		0.37	0.13	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	021	1	1	04	01	H4875_021_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H4875	021	1	1	04	01	H4875_021_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	021	1	1	04	01	H4875_021_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.08	50	50	50				30.62	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	021	1	1	04	01	H4875_021_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	021	2	1	04	01	H4875_021_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					4.00	8.00	0.00											11.00	22.00	33.00				4.00	8.00	0.00				11.00				11.00			0.37	0.13		0.37	0.13	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	021	2	1	04	01	H4875_021_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	0.00	20.00		20.00
H4875	021	2	1	04	01	H4875_021_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	021	2	1	04	01	H4875_021_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											29.08	50	50	50				30.62	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	021	2	1	04	01	H4875_021_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	022	1	1	04	01	H4875_022_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	022	1	1	04	01	H4875_022_1	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	022	1	1	04	01	H4875_022_1	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	022	1	1	04	01	H4875_022_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.66	50	50	50				69.29	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	022	1	1	04	01	H4875_022_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	26						1.00	26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	022	2	1	04	01	H4875_022_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	022	2	1	04	01	H4875_022_2	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	022	2	1	04	01	H4875_022_2	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	022	2	1	04	01	H4875_022_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.66	50	50	50				69.29	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	022	2	1	04	01	H4875_022_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	26						1.00	26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	022	5	1	04	01	H4875_022_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	022	5	1	04	01	H4875_022_5	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H4875	022	5	1	04	01	H4875_022_5	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	022	5	1	04	01	H4875_022_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.66	50	50	50				69.29	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	022	5	1	04	01	H4875_022_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	26						1.00	26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4875	023	0	1	04	01	H4875_023_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					3.00	6.00	0.00											11.00	22.00	33.00				3.00	6.00	0.00				11.00				11.00			0.37	0.10		0.37	0.10	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4875	023	0	1	04	01	H4875_023_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					10.00	20.00	30.00											18.00	36.00	54.00				10.00	20.00	0.00				18.00				18.00			0.60	0.33		0.60	0.33	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	10.00	20.00	30.00	18.00	36.00	54.00	10.00	20.00	0.00	18.00		18.00
H4875	023	0	1	04	01	H4875_023_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	023	0	1	04	01	H4875_023_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											31.48	50	50	50				28.85	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4875	023	0	1	04	01	H4875_023_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4882	003	0	1	04	01	H4882_003_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									4.00		12.00				4.00		8.00				4.00				4.00		0.13				0.13	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	003	0	1	04	01	H4882_003_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	10.00		30.00																									10.00		30.00				10.00		20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		30.00	10.00		20.00	10.00		10.00
H4882	003	0	1	04	01	H4882_003_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	003	0	1	04	01	H4882_003_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				77.04	40		40																								40		40				40		40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	003	0	1	04	01	H4882_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				819.11	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	004	0	1	04	01	H4882_004_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	004	0	1	04	01	H4882_004_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H4882	004	0	1	04	01	H4882_004_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	004	0	1	04	01	H4882_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				1	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	004	0	1	04	01	H4882_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				5663.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	005	0	1	04	01	H4882_005_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	005	0	1	04	01	H4882_005_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4882	005	0	1	04	01	H4882_005_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	9.00		27.00																									9.00		27.00				9.00		18.00				9.00				9.00		0.30				0.30	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				9.00		27.00	9.00		18.00	9.00		9.00
H4882	005	0	1	04	01	H4882_005_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				1	2				30		90	30		31	9.00		27.00																									9.00		27.00				9.00		18.00				9.00				9.00		0.30				0.30	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4882	005	0	1	04	01	H4882_005_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	005	0	1	04	01	H4882_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				1	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	005	0	1	04	01	H4882_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				862.85	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	009	1	1	04	01	H4882_009_1	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	009	1	1	04	01	H4882_009_1	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	14.00		42.00																									14.00		42.00				14.00		28.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00		42.00				14.00		42.00	14.00		28.00	14.00		14.00
H4882	009	1	1	04	01	H4882_009_1	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	009	1	1	04	01	H4882_009_1	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				65.68	35		35																								35		35				35		35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	009	1	1	04	01	H4882_009_1	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				646.05	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	009	2	1	04	01	H4882_009_2	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	009	2	1	04	01	H4882_009_2	9			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	14.00		42.00																									14.00		42.00				14.00		28.00				14.00				14.00		0.47				0.47	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00		42.00				14.00		42.00	14.00		28.00	14.00		14.00
H4882	009	2	1	04	01	H4882_009_2	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	009	2	1	04	01	H4882_009_2	9			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				65.68	35		35																								35		35				35		35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	009	2	1	04	01	H4882_009_2	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				646.05	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	010	1	1	04	01	H4882_010_1	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	010	1	1	04	01	H4882_010_1	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	10.00		30.00																									10.00		30.00				10.00		20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		30.00	10.00		20.00	10.00		10.00
H4882	010	1	1	04	01	H4882_010_1	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	010	1	1	04	01	H4882_010_1	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				82.31	40		40																								40		40				40		40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	010	1	1	04	01	H4882_010_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1088.20	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	010	2	1	04	01	H4882_010_2	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	010	2	1	04	01	H4882_010_2	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	10.00		30.00																									10.00		30.00				10.00		20.00				10.00				10.00		0.33				0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		30.00	10.00		20.00	10.00		10.00
H4882	010	2	1	04	01	H4882_010_2	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	010	2	1	04	01	H4882_010_2	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				82.31	40		40																								40		40				40		40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	010	2	1	04	01	H4882_010_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1088.20	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	011	1	1	04	01	H4882_011_1	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	011	1	1	04	01	H4882_011_1	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	12.00		36.00																									12.00		36.00				12.00		24.00				12.00				12.00		0.40				0.40	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				12.00		36.00	12.00		24.00	12.00		12.00
H4882	011	1	1	04	01	H4882_011_1	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	011	1	1	04	01	H4882_011_1	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				77.54	40		40																								40		40				40		40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	011	1	1	04	01	H4882_011_1	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				610.33	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	011	2	1	04	01	H4882_011_2	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4882	011	2	1	04	01	H4882_011_2	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	12.00		36.00																									12.00		36.00				12.00		24.00				12.00				12.00		0.40				0.40	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				12.00		36.00	12.00		24.00	12.00		12.00
H4882	011	2	1	04	01	H4882_011_2	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				1	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	011	2	1	04	01	H4882_011_2	8			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				77.54	40		40																								40		40				40		40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00
H4882	011	2	1	04	01	H4882_011_2	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				610.33	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4909	014	0	1	04	01	H4909_014_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	014	0	1	04	01	H4909_014_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	014	0	1	04	01	H4909_014_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H4909	014	0	1	04	01	H4909_014_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	014	0	1	04	01	H4909_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	014	0	1	04	01	H4909_014_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	014	0	1	04	01	H4909_014_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4909	015	0	1	04	01	H4909_015_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	015	0	1	04	01	H4909_015_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	015	0	1	04	01	H4909_015_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4909	015	0	1	04	01	H4909_015_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	015	0	1	04	01	H4909_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	015	0	1	04	01	H4909_015_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	015	0	1	04	01	H4909_015_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4909	016	0	1	04	01	H4909_016_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	016	0	1	04	01	H4909_016_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4909	016	0	1	04	01	H4909_016_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	016	0	1	04	01	H4909_016_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4909	016	0	1	04	01	H4909_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	016	0	1	04	01	H4909_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	016	0	1	04	01	H4909_016_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	016	0	1	04	01	H4909_016_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4909	026	0	1	04	01	H4909_026_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	026	0	1	04	01	H4909_026_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								18.00	36.00	54.00					13.00	26.00	39.00					0.00	0.00	0.00																18.00				18.00			0.60	0.43	0.00			0.53	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	026	0	1	04	01	H4909_026_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H4909	026	0	1	04	01	H4909_026_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	026	0	1	04	01	H4909_026_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	026	0	1	04	01	H4909_026_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4909	026	0	1	04	01	H4909_026_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4937	001	0	1	04	01	H4937_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4937	001	0	1	04	01	H4937_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4937	001	0	1	04	01	H4937_001_0	6			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					5.00	10.00	7.50							7.50																20.00				20.00			0.67	0.17				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4937	001	0	1	04	01	H4937_001_0	6			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					5.00	10.00	7.50							7.50																20.00				20.00			0.67	0.17				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4937	001	0	1	04	01	H4937_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H4937	001	0	1	04	01	H4937_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H4937	001	0	1	04	01	H4937_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4937	002	0	1	04	01	H4937_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4937	002	0	1	04	01	H4937_002_0	6			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H4937	002	0	1	04	01	H4937_002_0	6			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					10.00	20.00	15.00							15.00																20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4937	002	0	1	04	01	H4937_002_0	6			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					10.00	20.00	15.00							15.00																20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4937	002	0	1	04	01	H4937_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H4937	002	0	1	04	01	H4937_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	300.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H4937	002	0	1	04	01	H4937_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4943	001	0	1	01	01	H4943_001_0	16			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4943	001	0	1	01	01	H4943_001_0	16			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					5.00	10.00	10.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	10.00	0.00	0.00	0.00				10.00		10.00
H4943	001	0	1	01	01	H4943_001_0	16			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	94.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H4943	001	0	1	01	01	H4943_001_0	16			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	200.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H4943	001	0	1	01	01	H4943_001_0	16			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4961	001	0	1	04	01	H4961_001_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4961	001	0	1	04	01	H4961_001_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H4961	001	0	1	04	01	H4961_001_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	001	0	1	04	01	H4961_001_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	001	0	1	04	01	H4961_001_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1071.75	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	001	0	1	04	01	H4961_001_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	001	0	1	04	01	H4961_001_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4961	003	0	1	04	01	H4961_003_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4961	003	0	1	04	01	H4961_003_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H4961	003	0	1	04	01	H4961_003_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	003	0	1	04	01	H4961_003_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	003	0	1	04	01	H4961_003_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1030.73	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	003	0	1	04	01	H4961_003_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	003	0	1	04	01	H4961_003_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4961	006	0	1	04	01	H4961_006_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4961	006	0	1	04	01	H4961_006_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
H4961	006	0	1	04	01	H4961_006_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	006	0	1	04	01	H4961_006_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	93.00	186.00	279.00																			93.00	186.00	279.00																93.00				93.00		3.10			3.10			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	006	0	1	04	01	H4961_006_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				779.06	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	006	0	1	04	01	H4961_006_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	006	0	1	04	01	H4961_006_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	3.00	6.00	0.00																			3.00	6.00	0.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4961	007	0	1	04	01	H4961_007_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4961	007	0	1	04	01	H4961_007_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H4961	007	0	1	04	01	H4961_007_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	007	0	1	04	01	H4961_007_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	007	0	1	04	01	H4961_007_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				883.60	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	007	0	1	04	01	H4961_007_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	007	0	1	04	01	H4961_007_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4961	008	0	1	04	01	H4961_008_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H4961	008	0	1	04	01	H4961_008_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00	10.00	15.00				5.00	10.00	15.00				5.00		5.00
H4961	008	0	1	04	01	H4961_008_0	11			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	008	0	1	04	01	H4961_008_0	11			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H4961	008	0	1	04	01	H4961_008_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				773.56	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	008	0	1	04	01	H4961_008_0	11			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H4961	008	0	1	04	01	H4961_008_0	11			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H4982	001	0	1	01	01	H4982_001_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	001	0	1	01	01	H4982_001_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	001	0	1	01	01	H4982_001_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	001	0	1	01	01	H4982_001_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	001	0	1	01	01	H4982_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	001	0	1	01	01	H4982_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	001	0	1	01	01	H4982_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											731.91	33						520.85	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	002	0	1	01	01	H4982_002_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	002	0	1	01	01	H4982_002_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	002	0	1	01	01	H4982_002_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	002	0	1	01	01	H4982_002_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	002	0	1	01	01	H4982_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	002	0	1	01	01	H4982_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	002	0	1	01	01	H4982_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											856.80	33						674.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	003	0	1	01	01	H4982_003_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	003	0	1	01	01	H4982_003_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	003	0	1	01	01	H4982_003_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	003	0	1	01	01	H4982_003_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	003	0	1	01	01	H4982_003_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	003	0	1	01	01	H4982_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	003	0	1	01	01	H4982_003_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											892.65	33						634.99	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	004	0	1	01	01	H4982_004_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	004	0	1	01	01	H4982_004_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	004	0	1	01	01	H4982_004_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	004	0	1	01	01	H4982_004_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	004	0	1	01	01	H4982_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	004	0	1	01	01	H4982_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	004	0	1	01	01	H4982_004_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											793.94	33						593.34	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	005	0	1	01	01	H4982_005_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	005	0	1	01	01	H4982_005_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	005	0	1	01	01	H4982_005_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	005	0	1	01	01	H4982_005_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	005	0	1	01	01	H4982_005_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	005	0	1	01	01	H4982_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	005	0	1	01	01	H4982_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											957.32	33						675.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	006	0	1	01	01	H4982_006_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	006	0	1	01	01	H4982_006_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	006	0	1	01	01	H4982_006_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	006	0	1	01	01	H4982_006_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	006	0	1	01	01	H4982_006_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	006	0	1	01	01	H4982_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	006	0	1	01	01	H4982_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											869.31	33						607.88	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	007	0	1	01	01	H4982_007_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	007	0	1	01	01	H4982_007_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	007	0	1	01	01	H4982_007_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	007	0	1	01	01	H4982_007_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	007	0	1	01	01	H4982_007_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	007	0	1	01	01	H4982_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	007	0	1	01	01	H4982_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											771.21	33						481.19	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	010	0	1	01	01	H4982_010_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	010	0	1	01	01	H4982_010_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	010	0	1	01	01	H4982_010_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	010	0	1	01	01	H4982_010_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	010	0	1	01	01	H4982_010_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	010	0	1	01	01	H4982_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	010	0	1	01	01	H4982_010_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											789.49	33						560.93	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	011	0	1	01	01	H4982_011_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	011	0	1	01	01	H4982_011_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	011	0	1	01	01	H4982_011_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	011	0	1	01	01	H4982_011_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	011	0	1	01	01	H4982_011_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	011	0	1	01	01	H4982_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	011	0	1	01	01	H4982_011_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											848.49	33						562.68	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	012	0	1	01	01	H4982_012_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	012	0	1	01	01	H4982_012_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	012	0	1	01	01	H4982_012_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	012	0	1	01	01	H4982_012_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	012	0	1	01	01	H4982_012_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	012	0	1	01	01	H4982_012_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	012	0	1	01	01	H4982_012_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											791.19	33						537.03	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	017	0	1	02	01	H4982_017_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	017	0	1	02	01	H4982_017_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	017	0	1	02	01	H4982_017_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	017	0	1	02	01	H4982_017_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	017	0	1	02	01	H4982_017_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	017	0	1	02	01	H4982_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	017	0	1	02	01	H4982_017_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H4982	018	0	1	02	01	H4982_018_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	018	0	1	02	01	H4982_018_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	018	0	1	02	01	H4982_018_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H4982	018	0	1	02	01	H4982_018_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H4982	018	0	1	02	01	H4982_018_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					37.00	74.00	111.00											47.00	94.00	141.00				37.00	74.00	111.00					47.00			47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	018	0	1	02	01	H4982_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00					100.00			100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H4982	018	0	1	02	01	H4982_018_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.10	33						576.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5009	002	0	1	04	01	H5009_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5009	002	0	1	04	01	H5009_002_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H5009	002	0	1	04	01	H5009_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H5009	002	0	1	04	01	H5009_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	002	0	1	04	01	H5009_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5009	008	0	1	04	01	H5009_008_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5009	008	0	1	04	01	H5009_008_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H5009	008	0	1	04	01	H5009_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H5009	008	0	1	04	01	H5009_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	008	0	1	04	01	H5009_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1038.20	28						1038.20	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5009	010	0	1	04	01	H5009_010_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5009	010	0	1	04	01	H5009_010_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H5009	010	0	1	04	01	H5009_010_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	010	0	1	04	01	H5009_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	010	0	1	04	01	H5009_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1001.12	27						1001.12	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5009	011	1	1	04	01	H5009_011_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5009	011	1	1	04	01	H5009_011_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H5009	011	1	1	04	01	H5009_011_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	011	1	1	04	01	H5009_011_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	011	1	1	04	01	H5009_011_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1001.12	27						1001.12	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5009	011	2	1	04	01	H5009_011_2	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5009	011	2	1	04	01	H5009_011_2	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H5009	011	2	1	04	01	H5009_011_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	011	2	1	04	01	H5009_011_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	011	2	1	04	01	H5009_011_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1001.12	27						1001.12	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5009	011	3	1	04	01	H5009_011_3	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5009	011	3	1	04	01	H5009_011_3	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H5009	011	3	1	04	01	H5009_011_3	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	011	3	1	04	01	H5009_011_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5009	011	3	1	04	01	H5009_011_3	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1001.12	27						1001.12	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5010	008	1	1	04	01	H5010_008_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5010	008	1	1	04	01	H5010_008_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H5010	008	1	1	04	01	H5010_008_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5010	008	1	1	04	01	H5010_008_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5010	008	1	1	04	01	H5010_008_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1001.12	27						1001.12	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5010	008	2	1	04	01	H5010_008_2	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5010	008	2	1	04	01	H5010_008_2	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	0.00				20.00		20.00
H5010	008	2	1	04	01	H5010_008_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5010	008	2	1	04	01	H5010_008_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5010	008	2	1	04	01	H5010_008_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1001.12	27						1001.12	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5010	009	1	1	04	01	H5010_009_1	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5010	009	1	1	04	01	H5010_009_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H5010	009	1	1	04	01	H5010_009_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H5010	009	1	1	04	01	H5010_009_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5010	009	1	1	04	01	H5010_009_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5010	009	2	1	04	01	H5010_009_2	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H5010	009	2	1	04	01	H5010_009_2	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					13.00	26.00	26.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	13.00	26.00	26.00	13.00	26.00	26.00				20.00		20.00
H5010	009	2	1	04	01	H5010_009_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H5010	009	2	1	04	01	H5010_009_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5010	009	2	1	04	01	H5010_009_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1075.28	29						1075.28	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	009	0	1	04	01	H5042_009_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	009	0	1	04	01	H5042_009_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	009	0	1	04	01	H5042_009_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H5042	009	0	1	04	01	H5042_009_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	250.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	009	0	1	04	01	H5042_009_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1399.46	26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	011	0	1	04	01	H5042_011_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	011	0	1	04	01	H5042_011_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	011	0	1	04	01	H5042_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					44.00	88.00	132.00											47.00	94.00	141.00				44.00	88.00	88.00				47.00				47.00			1.57	1.47		1.57	1.47	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00
H5042	011	0	1	04	01	H5042_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								95.00	190.00	285.00					95.00	190.00	285.00											95.00	190.00	285.00				95.00	190.00	237.50				95.00				95.00			3.17	3.17		3.17	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5042	011	0	1	04	01	H5042_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1399.46	33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5050	004	0	1	01	01	H5050_004_0	12			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H5050	004	0	1	01	01	H5050_004_0	12			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	004	0	1	01	01	H5050_004_0	12			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					5.00	0.00	0.00																20.00				20.00			0.66	0.16	0.16			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	5.00	0.00	0.00				20.00		20.00
H5050	004	0	1	01	01	H5050_004_0	12			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								45.00	90.00	135.00					45.00	90.00	135.00					45.00	90.00	112.50																45.00				45.00			1.50	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	004	0	1	01	01	H5050_004_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	297.00					99.00	198.00	247.50																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	004	0	1	01	01	H5050_004_0	12			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	004	0	1	01	01	H5050_004_0	12			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	004	0	1	01	01	H5050_004_0	12			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	009	0	1	01	01	H5050_009_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H5050	009	0	1	01	01	H5050_009_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	009	0	1	01	01	H5050_009_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					5.00	0.00	0.00																20.00				20.00			0.66	0.16	0.16			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	5.00	0.00	0.00				20.00		20.00
H5050	009	0	1	01	01	H5050_009_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								45.00	90.00	135.00					45.00	90.00	135.00					45.00	90.00	112.50																45.00				45.00			1.50	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	009	0	1	01	01	H5050_009_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	297.00					99.00	198.00	247.50																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	009	0	1	01	01	H5050_009_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	009	0	1	01	01	H5050_009_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	009	0	1	01	01	H5050_009_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	013	0	1	01	01	H5050_013_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H5050	013	0	1	01	01	H5050_013_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	013	0	1	01	01	H5050_013_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					5.00	0.00	0.00																20.00				20.00			0.66	0.16	0.16			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	5.00	10.00	15.00	5.00	0.00	0.00				20.00		20.00
H5050	013	0	1	01	01	H5050_013_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	117.50																47.00				47.00			1.56	1.56	1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	013	0	1	01	01	H5050_013_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	297.00					99.00	198.00	247.50																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	013	0	1	01	01	H5050_013_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	013	0	1	01	01	H5050_013_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	013	0	1	01	01	H5050_013_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	017	0	1	01	01	H5050_017_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								3.00	6.00	9.00					0.00	0.00	0.00					0.00	0.00	0.00																3.00				3.00			0.10	0.00	0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													3.00	6.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00				3.00		3.00
H5050	017	0	1	01	01	H5050_017_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								3.00	6.00	9.00					0.00	0.00	0.00					0.00	0.00	0.00																3.00				3.00			0.10	0.00	0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	017	0	1	01	01	H5050_017_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								9.00	18.00	27.00					5.00	10.00	15.00					5.00	0.00	0.00																9.00				9.00			0.30	0.16	0.16			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													9.00	18.00	27.00	5.00	10.00	15.00	5.00	0.00	0.00				9.00		9.00
H5050	017	0	1	01	01	H5050_017_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	117.50																47.00				47.00			1.56	1.56	1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	017	0	1	01	01	H5050_017_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	297.00					99.00	198.00	247.50																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	017	0	1	01	01	H5050_017_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												30	30	30					30	30	30				30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	017	0	1	01	01	H5050_017_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	017	0	1	01	01	H5050_017_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	019	0	1	01	01	H5050_019_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					2.00	4.00	6.00					2.00	0.00	0.00																10.00				10.00			0.33	0.06	0.06			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	2.00	4.00	6.00	2.00	0.00	0.00				10.00		10.00
H5050	019	0	1	01	01	H5050_019_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					2.00	4.00	6.00					2.00	0.00	0.00																10.00				10.00			0.33	0.06	0.06			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	019	0	1	01	01	H5050_019_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	21.00					7.00	0.00	0.00																20.00				20.00			0.66	0.23	0.23			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	7.00	14.00	21.00	7.00	0.00	0.00				20.00		20.00
H5050	019	0	1	01	01	H5050_019_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	100.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
H5050	019	0	1	01	01	H5050_019_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	225.00																100.00				100.00			3.33	3.00	3.00			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	019	0	1	01	01	H5050_019_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	019	0	1	01	01	H5050_019_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	019	0	1	01	01	H5050_019_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	021	0	1	01	01	H5050_021_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					2.00	4.00	6.00					2.00	0.00	0.00																10.00				10.00			0.33	0.06	0.06			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	2.00	4.00	6.00	2.00	0.00	0.00				10.00		10.00
H5050	021	0	1	01	01	H5050_021_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					2.00	4.00	6.00					2.00	0.00	0.00																10.00				10.00			0.33	0.06	0.06			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	021	0	1	01	01	H5050_021_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	21.00					7.00	0.00	0.00																20.00				20.00			0.66	0.23	0.23			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	7.00	14.00	21.00	7.00	0.00	0.00				20.00		20.00
H5050	021	0	1	01	01	H5050_021_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	112.50																47.00				47.00			1.56	1.50	1.50			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	021	0	1	01	01	H5050_021_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	237.50																100.00				100.00			3.33	3.16	3.16			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	021	0	1	01	01	H5050_021_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												30	30	30					30	30	30				30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	021	0	1	01	01	H5050_021_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	021	0	1	01	01	H5050_021_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	022	0	1	01	01	H5050_022_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00
H5050	022	0	1	01	01	H5050_022_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	022	0	1	01	01	H5050_022_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					7.00	14.00	21.00					7.00	0.00	0.00																20.00				20.00			0.66	0.23	0.23			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	7.00	14.00	21.00	7.00	0.00	0.00				20.00		20.00
H5050	022	0	1	01	01	H5050_022_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	117.50																47.00				47.00			1.56	1.56	1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	022	0	1	01	01	H5050_022_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	297.00					99.00	198.00	247.50																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	022	0	1	01	01	H5050_022_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												31	31	31					31	31	31				31	31	31															31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	022	0	1	01	01	H5050_022_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	022	0	1	01	01	H5050_022_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	023	0	1	01	01	H5050_023_0	10			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00
H5050	023	0	1	01	01	H5050_023_0	10			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5050	023	0	1	01	01	H5050_023_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								14.00	28.00	42.00					9.00	18.00	27.00					9.00	0.00	0.00																14.00				14.00			0.46	0.30	0.30			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	9.00	18.00	27.00	9.00	0.00	0.00				14.00		14.00
H5050	023	0	1	01	01	H5050_023_0	10			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	117.50																47.00				47.00			1.56	1.56	1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	023	0	1	01	01	H5050_023_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								99.00	198.00	297.00					99.00	198.00	297.00					99.00	198.00	247.50																99.00				99.00			3.30	3.30	3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	023	0	1	01	01	H5050_023_0	10			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												29	29	29					29	29	29				29	29	29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5050	023	0	1	01	01	H5050_023_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5050	023	0	1	01	01	H5050_023_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5087	005	0	1	01	01	H5087_005_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	005	0	1	01	01	H5087_005_0	16			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5087	005	0	1	01	01	H5087_005_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	005	0	1	01	01	H5087_005_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5087	005	0	1	01	01	H5087_005_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.45	38	38	38				98.45	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5087	005	0	1	01	01	H5087_005_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5087	005	0	1	01	01	H5087_005_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	005	0	1	01	01	H5087_005_0	16			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5087	016	0	1	01	01	H5087_016_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	016	0	1	01	01	H5087_016_0	16			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5087	016	0	1	01	01	H5087_016_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	0.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	016	0	1	01	01	H5087_016_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5087	016	0	1	01	01	H5087_016_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.45	48	48	48				98.45	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5087	016	0	1	01	01	H5087_016_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5087	016	0	1	01	01	H5087_016_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	016	0	1	01	01	H5087_016_0	16			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5087	024	0	1	01	01	H5087_024_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	024	0	1	01	01	H5087_024_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	024	0	1	01	01	H5087_024_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5087	024	0	1	01	01	H5087_024_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.34	50	50	50				84.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5087	024	0	1	01	01	H5087_024_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5087	024	0	1	01	01	H5087_024_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	032	0	1	01	01	H5087_032_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	032	0	1	01	01	H5087_032_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	032	0	1	01	01	H5087_032_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5087	032	0	1	01	01	H5087_032_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.27	43	43	43				99.27	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5087	032	0	1	01	01	H5087_032_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5087	032	0	1	01	01	H5087_032_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	032	0	1	01	01	H5087_032_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5087	033	0	1	01	01	H5087_033_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	033	0	1	01	01	H5087_033_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	033	0	1	01	01	H5087_033_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H5087	033	0	1	01	01	H5087_033_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.88	46	46	46				98.88	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5087	033	0	1	01	01	H5087_033_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H5087	033	0	1	01	01	H5087_033_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5087	033	0	1	01	01	H5087_033_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5106	013	0	1	04	01	H5106_013_0	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													15.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	013	0	1	04	01	H5106_013_0	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								19.00		57.00					11.00		33.00													57.00						27.00				19.00				19.00			0.61	0.35				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	013	0	1	04	01	H5106_013_0	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					45.00		135.00													141.00						115.00				47.00				47.00			1.52	1.45				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H5106	013	0	1	04	01	H5106_013_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H5106	013	0	1	04	01	H5106_013_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1493.02	33						1493.02	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	029	1	1	04	01	H5106_029_1	9			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	029	1	1	04	01	H5106_029_1	9			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	029	1	1	04	01	H5106_029_1	9			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	029	1	1	04	01	H5106_029_1	9			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	029	1	1	04	01	H5106_029_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1131.14	33						1131.14	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	029	2	1	04	01	H5106_029_2	9			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	029	2	1	04	01	H5106_029_2	9			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	029	2	1	04	01	H5106_029_2	9			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						120.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	029	2	1	04	01	H5106_029_2	9			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	029	2	1	04	01	H5106_029_2	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1131.14	33						1131.14	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	030	1	1	04	01	H5106_030_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	030	1	1	04	01	H5106_030_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					5.00		15.00													60.00						0.00				20.00				20.00			0.65	0.16				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	030	1	1	04	01	H5106_030_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	030	1	1	04	01	H5106_030_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	030	1	1	04	01	H5106_030_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1050.09	33						1050.09	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	030	2	1	04	01	H5106_030_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	030	2	1	04	01	H5106_030_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					5.00		15.00													60.00						0.00				20.00				20.00			0.65	0.16				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	030	2	1	04	01	H5106_030_2	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	030	2	1	04	01	H5106_030_2	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	030	2	1	04	01	H5106_030_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1050.09	33						1050.09	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	031	1	1	04	01	H5106_031_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	031	1	1	04	01	H5106_031_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					10.00		30.00													60.00						10.00				20.00				20.00			0.65	0.32				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	031	1	1	04	01	H5106_031_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	031	1	1	04	01	H5106_031_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	031	1	1	04	01	H5106_031_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1060.79	25						1060.79	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	031	2	1	04	01	H5106_031_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	031	2	1	04	01	H5106_031_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					10.00		30.00													60.00						10.00				20.00				20.00			0.65	0.32				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	031	2	1	04	01	H5106_031_2	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	031	2	1	04	01	H5106_031_2	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	031	2	1	04	01	H5106_031_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1060.79	25						1060.79	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	032	1	1	04	01	H5106_032_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	032	1	1	04	01	H5106_032_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	032	1	1	04	01	H5106_032_1	7			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						105.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	20.00		60.00			60.00			60.00	20		20
H5106	032	1	1	04	01	H5106_032_1	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	032	1	1	04	01	H5106_032_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1221.70	33						1221.70	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	032	2	1	04	01	H5106_032_2	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	032	2	1	04	01	H5106_032_2	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5106	032	2	1	04	01	H5106_032_2	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					42.00		126.00													141.00						105.00				47.00				47.00			1.52	1.35				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	20.00		60.00			60.00			60.00	20		20
H5106	032	2	1	04	01	H5106_032_2	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35		35
H5106	032	2	1	04	01	H5106_032_2	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1221.70	33						1221.70	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5140	001	0	1	04	01	H5140_001_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5140	001	0	1	04	01	H5140_001_0	12			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00
H5140	001	0	1	04	01	H5140_001_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5140	001	0	1	04	01	H5140_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5140	001	0	1	04	01	H5140_001_0	12			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					33	33																																				33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00											35.00		35.00
H5140	001	0	1	04	01	H5140_001_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5140	002	0	1	04	01	H5140_002_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5140	002	0	1	04	01	H5140_002_0	9			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00
H5140	002	0	1	04	01	H5140_002_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5140	002	0	1	04	01	H5140_002_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5140	002	0	1	04	01	H5140_002_0	9			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					33	33																																				33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00											35.00		35.00
H5140	002	0	1	04	01	H5140_002_0	9			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5141	001	0	1	04	01	H5141_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	001	0	1	04	01	H5141_001_0	11			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	001	0	1	04	01	H5141_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	001	0	1	04	01	H5141_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	001	0	1	04	01	H5141_001_0	11			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					30	30	30																				30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	004	0	1	04	01	H5141_004_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	004	0	1	04	01	H5141_004_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	004	0	1	04	01	H5141_004_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	004	0	1	04	01	H5141_004_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	004	0	1	04	01	H5141_004_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					30	30	30																				30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	007	0	1	04	01	H5141_007_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	007	0	1	04	01	H5141_007_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	007	0	1	04	01	H5141_007_0	10			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				52.98	23	23	23																				22															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	007	0	1	04	01	H5141_007_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				90.80	34	34	34																				30															34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	007	0	1	04	01	H5141_007_0	10			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	025	0	1	04	01	H5141_025_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	025	0	1	04	01	H5141_025_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	025	0	1	04	01	H5141_025_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	025	0	1	04	01	H5141_025_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	025	0	1	04	01	H5141_025_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					33	33	33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	026	0	1	04	01	H5141_026_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	026	0	1	04	01	H5141_026_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	026	0	1	04	01	H5141_026_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	026	0	1	04	01	H5141_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	026	0	1	04	01	H5141_026_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					33	33	33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	032	0	1	04	01	H5141_032_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	032	0	1	04	01	H5141_032_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	032	0	1	04	01	H5141_032_0	10			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	032	0	1	04	01	H5141_032_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	032	0	1	04	01	H5141_032_0	10			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					33	33	33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	036	0	1	04	01	H5141_036_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	036	0	1	04	01	H5141_036_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	036	0	1	04	01	H5141_036_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	036	0	1	04	01	H5141_036_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	036	0	1	04	01	H5141_036_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					33	33	33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	038	0	1	04	01	H5141_038_0	10			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	038	0	1	04	01	H5141_038_0	10			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	038	0	1	04	01	H5141_038_0	10			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	038	0	1	04	01	H5141_038_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	038	0	1	04	01	H5141_038_0	10			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					33	33	33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	042	0	1	04	01	H5141_042_0	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	042	0	1	04	01	H5141_042_0	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	042	0	1	04	01	H5141_042_0	8			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				43.52	22	22	22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	042	0	1	04	01	H5141_042_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				90.16	35	35	35																				30															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	042	0	1	04	01	H5141_042_0	8			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	045	0	1	04	01	H5141_045_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	045	0	1	04	01	H5141_045_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	045	0	1	04	01	H5141_045_0	9			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				46.35	23	23	23																				22															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	045	0	1	04	01	H5141_045_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				90.97	33	33	33																				30															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	045	0	1	04	01	H5141_045_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	054	0	1	04	01	H5141_054_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	054	0	1	04	01	H5141_054_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	054	0	1	04	01	H5141_054_0	9			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				60.35	25	25	25																				22															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	054	0	1	04	01	H5141_054_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				96.78	41	41	41																				35															41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	054	0	1	04	01	H5141_054_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					28	28	28																				28															28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	055	0	1	04	01	H5141_055_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	055	0	1	04	01	H5141_055_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	055	0	1	04	01	H5141_055_0	9			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				56.36	23	23	23																				22															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	055	0	1	04	01	H5141_055_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				92.71	33	33	33																				30															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	055	0	1	04	01	H5141_055_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	058	0	1	04	01	H5141_058_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	058	0	1	04	01	H5141_058_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	058	0	1	04	01	H5141_058_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	058	0	1	04	01	H5141_058_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	058	0	1	04	01	H5141_058_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					30	30	30																				30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	059	0	1	04	01	H5141_059_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	059	0	1	04	01	H5141_059_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5141	059	0	1	04	01	H5141_059_0	9			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				50.51	22	22	22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	059	0	1	04	01	H5141_059_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				94.63	36	36	36																				30															36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5141	059	0	1	04	01	H5141_059_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H5163	001	0	1	01	01	H5163_001_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5163	001	0	1	01	01	H5163_001_0	9			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5163	001	0	1	01	01	H5163_001_0	9			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5163	001	0	1	01	01	H5163_001_0	9			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5163	001	0	1	01	01	H5163_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	35.00	70.00	105.00																			35.00	70.00	70.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5163	001	0	1	01	01	H5163_001_0	9			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5163	001	0	1	01	01	H5163_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1000.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5163	002	0	1	01	01	H5163_002_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5163	002	0	1	01	01	H5163_002_0	8			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5163	002	0	1	01	01	H5163_002_0	8			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5163	002	0	1	01	01	H5163_002_0	8			Generic	4	01	3	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5163	002	0	1	01	01	H5163_002_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	32.00	64.00	96.00																			32.00	64.00	64.00																32.00				32.00		1.07			1.07			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													32.00	64.00	96.00				32.00	64.00	64.00				32.00		32.00
H5163	002	0	1	01	01	H5163_002_0	8			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5163	002	0	1	01	01	H5163_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1000.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5163	002	0	1	01	01	H5163_002_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5163	002	0	1	01	01	H5163_002_0	8			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5178	002	0	1	01	01	H5178_002_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5178	002	0	1	01	01	H5178_002_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5178	002	0	1	01	01	H5178_002_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5178	002	0	1	01	01	H5178_002_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5178	002	0	1	01	01	H5178_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5178	002	0	1	01	01	H5178_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5178	002	0	1	01	01	H5178_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5199	008	0	1	04	01	H5199_008_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	008	0	1	04	01	H5199_008_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5199	008	0	1	04	01	H5199_008_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	008	0	1	04	01	H5199_008_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5199	008	0	1	04	01	H5199_008_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											94.31	50	50	50				94.31	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5199	008	0	1	04	01	H5199_008_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5199	008	0	1	04	01	H5199_008_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	008	0	1	04	01	H5199_008_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5199	010	0	1	04	01	H5199_010_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	010	0	1	04	01	H5199_010_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5199	010	0	1	04	01	H5199_010_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	010	0	1	04	01	H5199_010_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H5199	010	0	1	04	01	H5199_010_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.87	46	46	46				97.87	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5199	010	0	1	04	01	H5199_010_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H5199	010	0	1	04	01	H5199_010_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	010	0	1	04	01	H5199_010_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5199	012	0	1	04	01	H5199_012_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	012	0	1	04	01	H5199_012_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5199	012	0	1	04	01	H5199_012_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	012	0	1	04	01	H5199_012_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5199	012	0	1	04	01	H5199_012_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.78	40	40	40				97.78	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5199	012	0	1	04	01	H5199_012_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5199	012	0	1	04	01	H5199_012_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	012	0	1	04	01	H5199_012_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5199	014	0	1	04	01	H5199_014_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	014	0	1	04	01	H5199_014_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5199	014	0	1	04	01	H5199_014_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	014	0	1	04	01	H5199_014_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5199	014	0	1	04	01	H5199_014_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.01	50	50	50				81.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5199	014	0	1	04	01	H5199_014_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H5199	014	0	1	04	01	H5199_014_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5199	014	0	1	04	01	H5199_014_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5211	002	0	1	02	01	H5211_002_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	2.00	4.00	6.00																			2.00	4.00	6.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	002	0	1	02	01	H5211_002_0	5			Generic	4	11	1	2	2	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	9.00	18.00	27.00																			9.00	18.00	27.00																9.00				9.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													9.00	18.00	27.00				9.00	18.00	27.00				9.00		9.00
H5211	002	0	1	02	01	H5211_002_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.38			1.38			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	002	0	1	02	01	H5211_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		2.94			2.94			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	002	0	1	02	01	H5211_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				1882.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	002	0	1	02	01	H5211_002_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	1	010		01	000		1	34														34		34	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	004	0	1	02	01	H5211_004_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	9.00	18.00	27.00																			9.00	18.00	27.00																9.00				9.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	004	0	1	02	01	H5211_004_0	4			Generic	4	11	1	2	2	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.59			0.59			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H5211	004	0	1	02	01	H5211_004_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.38			1.38			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	004	0	1	02	01	H5211_004_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		2.94			2.94			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	004	0	1	02	01	H5211_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				2716.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	004	0	1	02	01	H5211_004_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	010		01	000		1	34														34		34	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	012	0	1	02	01	H5211_012_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	4.00	8.00	12.00																			4.00	8.00	12.00																4.00				4.00		0.12			0.12			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	012	0	1	02	01	H5211_012_0	4			Generic	4	11	1	2	2	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	16.00	32.00	48.00																			16.00	32.00	48.00																16.00				16.00		0.47			0.47			0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													16.00	32.00	48.00				16.00	32.00	48.00				16.00		16.00
H5211	012	0	1	02	01	H5211_012_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.38			1.38			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	012	0	1	02	01	H5211_012_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		2.94			2.94			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	012	0	1	02	01	H5211_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				1842.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	012	0	1	02	01	H5211_012_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	010		01	000		1	34														34		34	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	013	0	1	02	01	H5211_013_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	2.00	4.00	6.00																			2.00	4.00	6.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	013	0	1	02	01	H5211_013_0	4			Generic	4	11	1	2	2	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	9.00	18.00	27.00																			9.00	18.00	27.00																9.00				9.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													9.00	18.00	27.00				9.00	18.00	27.00				9.00		9.00
H5211	013	0	1	02	01	H5211_013_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.38			1.38			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	013	0	1	02	01	H5211_013_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		2.94			2.94			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5211	013	0	1	02	01	H5211_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				1882.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5211	013	0	1	02	01	H5211_013_0	4			Vaccines ($0 cost sharing)	4	11	1	2	6	1	010		01	000		1	34														34		34	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5215	002	0	1	04	01	H5215_002_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	002	0	1	04	01	H5215_002_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	002	0	1	04	01	H5215_002_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	002	0	1	04	01	H5215_002_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	002	0	1	04	01	H5215_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	005	0	1	04	01	H5215_005_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	005	0	1	04	01	H5215_005_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	005	0	1	04	01	H5215_005_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	005	0	1	04	01	H5215_005_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	005	0	1	04	01	H5215_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	007	0	1	04	01	H5215_007_0	6		N	Preferred Generic	3	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								15.00		37.00					7.00		17.00											15.00		37.00				7.00		0.00				7.00				7.00			0.50	0.23		0.50	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	007	0	1	04	01	H5215_007_0	6		N	Generic	3	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								20.00		50.00					13.00		32.00											20.00		50.00				13.00		0.00				13.00				13.00			0.67	0.43		0.67	0.43	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	007	0	1	04	01	H5215_007_0	6		N	Preferred Brand	3	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	007	0	1	04	01	H5215_007_0	6		N	Non-Preferred Drug	3	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	007	0	1	04	01	H5215_007_0	6		N	Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	008	0	1	04	01	H5215_008_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	008	0	1	04	01	H5215_008_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	008	0	1	04	01	H5215_008_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	008	0	1	04	01	H5215_008_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	008	0	1	04	01	H5215_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	009	0	1	04	01	H5215_009_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	009	0	1	04	01	H5215_009_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	009	0	1	04	01	H5215_009_0	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	009	0	1	04	01	H5215_009_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	009	0	1	04	01	H5215_009_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	010	0	1	04	01	H5215_010_0	6			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	010	0	1	04	01	H5215_010_0	6			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	010	0	1	04	01	H5215_010_0	6			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	010	0	1	04	01	H5215_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	010	0	1	04	01	H5215_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	011	0	1	04	01	H5215_011_0	6			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	011	0	1	04	01	H5215_011_0	6			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	011	0	1	04	01	H5215_011_0	6			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	011	0	1	04	01	H5215_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	011	0	1	04	01	H5215_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	012	0	1	04	01	H5215_012_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								7.00		17.00					2.00		5.00											7.00		17.00				2.00		0.00				2.00				2.00			0.23	0.07		0.23	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	012	0	1	04	01	H5215_012_0	8			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		37.00					8.00		20.00											15.00		37.00				8.00		0.00				8.00				8.00			0.50	0.27		0.50	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5215	012	0	1	04	01	H5215_012_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		117.00					42.00		105.00											47.00		117.00				42.00		105.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	012	0	1	04	01	H5215_012_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				30		90	1	2				30		90	30		31								100.00		250.00					95.00		237.00											100.00		250.00				95.00		237.00				95.00				95.00			3.33	3.17		3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5215	012	0	1	04	01	H5215_012_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5216	001	0	1	04	01	H5216_001_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5216	001	0	1	04	01	H5216_001_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	001	0	1	04	01	H5216_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	001	0	1	04	01	H5216_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	001	0	1	04	01	H5216_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	006	0	1	04	01	H5216_006_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	006	0	1	04	01	H5216_006_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	006	0	1	04	01	H5216_006_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	006	0	1	04	01	H5216_006_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	006	0	1	04	01	H5216_006_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	006	0	1	04	01	H5216_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	006	0	1	04	01	H5216_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	011	0	1	04	01	H5216_011_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5216	011	0	1	04	01	H5216_011_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	011	0	1	04	01	H5216_011_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	011	0	1	04	01	H5216_011_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	011	0	1	04	01	H5216_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	013	0	1	04	01	H5216_013_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5216	013	0	1	04	01	H5216_013_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	013	0	1	04	01	H5216_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	013	0	1	04	01	H5216_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	013	0	1	04	01	H5216_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	014	0	1	04	01	H5216_014_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5216	014	0	1	04	01	H5216_014_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	16.00		48.00																									20.00		60.00				16.00		0.00				16.00				16.00		0.53				0.67	0.53	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													16.00		48.00				20.00		60.00	16.00		0.00	16.00		16.00
H5216	014	0	1	04	01	H5216_014_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	014	0	1	04	01	H5216_014_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	014	0	1	04	01	H5216_014_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	017	0	1	04	01	H5216_017_0	10			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	017	0	1	04	01	H5216_017_0	10			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	017	0	1	04	01	H5216_017_0	10			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	017	0	1	04	01	H5216_017_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	017	0	1	04	01	H5216_017_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	019	0	1	04	01	H5216_019_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	019	0	1	04	01	H5216_019_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	019	0	1	04	01	H5216_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	019	0	1	04	01	H5216_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	019	0	1	04	01	H5216_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	023	0	1	04	01	H5216_023_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	023	0	1	04	01	H5216_023_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5216	023	0	1	04	01	H5216_023_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	023	0	1	04	01	H5216_023_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	023	0	1	04	01	H5216_023_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	024	0	1	04	01	H5216_024_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	024	0	1	04	01	H5216_024_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	024	0	1	04	01	H5216_024_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	024	0	1	04	01	H5216_024_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	024	0	1	04	01	H5216_024_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	024	0	1	04	01	H5216_024_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	024	0	1	04	01	H5216_024_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	027	0	1	04	01	H5216_027_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	027	0	1	04	01	H5216_027_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	027	0	1	04	01	H5216_027_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	027	0	1	04	01	H5216_027_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	027	0	1	04	01	H5216_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	032	0	1	04	01	H5216_032_0	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	8.00		24.00																									10.00		30.00				8.00		0.00				8.00				8.00		0.27				0.33	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				10.00		30.00	8.00		0.00	8.00		8.00
H5216	032	0	1	04	01	H5216_032_0	9			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	032	0	1	04	01	H5216_032_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	032	0	1	04	01	H5216_032_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	032	0	1	04	01	H5216_032_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	034	0	1	04	01	H5216_034_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	034	0	1	04	01	H5216_034_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	034	0	1	04	01	H5216_034_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	034	0	1	04	01	H5216_034_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	034	0	1	04	01	H5216_034_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	037	0	1	04	01	H5216_037_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	037	0	1	04	01	H5216_037_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	037	0	1	04	01	H5216_037_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	037	0	1	04	01	H5216_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	037	0	1	04	01	H5216_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	039	0	1	04	01	H5216_039_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	039	0	1	04	01	H5216_039_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	039	0	1	04	01	H5216_039_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	039	0	1	04	01	H5216_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	039	0	1	04	01	H5216_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	042	0	1	04	01	H5216_042_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	042	0	1	04	01	H5216_042_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	042	0	1	04	01	H5216_042_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	042	0	1	04	01	H5216_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	042	0	1	04	01	H5216_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	043	1	1	04	01	H5216_043_1	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	043	1	1	04	01	H5216_043_1	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	043	1	1	04	01	H5216_043_1	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	043	1	1	04	01	H5216_043_1	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	043	1	1	04	01	H5216_043_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	043	1	1	04	01	H5216_043_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	043	1	1	04	01	H5216_043_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	043	5	1	04	01	H5216_043_5	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	043	5	1	04	01	H5216_043_5	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	043	5	1	04	01	H5216_043_5	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	043	5	1	04	01	H5216_043_5	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	043	5	1	04	01	H5216_043_5	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	043	5	1	04	01	H5216_043_5	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	043	5	1	04	01	H5216_043_5	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	043	6	1	04	01	H5216_043_6	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	043	6	1	04	01	H5216_043_6	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	043	6	1	04	01	H5216_043_6	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	043	6	1	04	01	H5216_043_6	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	043	6	1	04	01	H5216_043_6	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	043	6	1	04	01	H5216_043_6	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	043	6	1	04	01	H5216_043_6	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	044	0	1	04	01	H5216_044_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	044	0	1	04	01	H5216_044_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	044	0	1	04	01	H5216_044_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	044	0	1	04	01	H5216_044_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	044	0	1	04	01	H5216_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	044	0	1	04	01	H5216_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	044	0	1	04	01	H5216_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	047	0	1	04	01	H5216_047_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	047	0	1	04	01	H5216_047_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	047	0	1	04	01	H5216_047_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	047	0	1	04	01	H5216_047_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	047	0	1	04	01	H5216_047_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	047	0	1	04	01	H5216_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	047	0	1	04	01	H5216_047_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	053	0	1	04	01	H5216_053_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	053	0	1	04	01	H5216_053_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5216	053	0	1	04	01	H5216_053_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	053	0	1	04	01	H5216_053_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	053	0	1	04	01	H5216_053_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	057	0	1	04	01	H5216_057_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	057	0	1	04	01	H5216_057_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	057	0	1	04	01	H5216_057_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	057	0	1	04	01	H5216_057_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	057	0	1	04	01	H5216_057_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	057	0	1	04	01	H5216_057_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	057	0	1	04	01	H5216_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	058	0	1	04	01	H5216_058_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	058	0	1	04	01	H5216_058_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	058	0	1	04	01	H5216_058_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5216	058	0	1	04	01	H5216_058_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	058	0	1	04	01	H5216_058_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	058	0	1	04	01	H5216_058_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	058	0	1	04	01	H5216_058_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	062	0	1	04	01	H5216_062_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	062	0	1	04	01	H5216_062_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	062	0	1	04	01	H5216_062_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H5216	062	0	1	04	01	H5216_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	062	0	1	04	01	H5216_062_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	063	0	1	04	01	H5216_063_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	063	0	1	04	01	H5216_063_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	063	0	1	04	01	H5216_063_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	063	0	1	04	01	H5216_063_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	063	0	1	04	01	H5216_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	063	0	1	04	01	H5216_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	063	0	1	04	01	H5216_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	064	0	1	04	01	H5216_064_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	064	0	1	04	01	H5216_064_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	064	0	1	04	01	H5216_064_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	064	0	1	04	01	H5216_064_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	064	0	1	04	01	H5216_064_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	068	0	1	04	01	H5216_068_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	068	0	1	04	01	H5216_068_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	068	0	1	04	01	H5216_068_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	068	0	1	04	01	H5216_068_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	068	0	1	04	01	H5216_068_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	070	0	1	04	01	H5216_070_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	070	0	1	04	01	H5216_070_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	070	0	1	04	01	H5216_070_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	070	0	1	04	01	H5216_070_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	070	0	1	04	01	H5216_070_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	070	0	1	04	01	H5216_070_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	070	0	1	04	01	H5216_070_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	072	0	1	04	01	H5216_072_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	072	0	1	04	01	H5216_072_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	072	0	1	04	01	H5216_072_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	072	0	1	04	01	H5216_072_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	072	0	1	04	01	H5216_072_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	072	0	1	04	01	H5216_072_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	072	0	1	04	01	H5216_072_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	073	0	1	04	01	H5216_073_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	073	0	1	04	01	H5216_073_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5216	073	0	1	04	01	H5216_073_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	073	0	1	04	01	H5216_073_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	073	0	1	04	01	H5216_073_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	074	0	1	04	01	H5216_074_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	074	0	1	04	01	H5216_074_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	074	0	1	04	01	H5216_074_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	074	0	1	04	01	H5216_074_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	074	0	1	04	01	H5216_074_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	074	0	1	04	01	H5216_074_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	074	0	1	04	01	H5216_074_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	078	1	1	04	01	H5216_078_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	078	1	1	04	01	H5216_078_1	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	078	1	1	04	01	H5216_078_1	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	078	1	1	04	01	H5216_078_1	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	078	1	1	04	01	H5216_078_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	078	1	1	04	01	H5216_078_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	078	1	1	04	01	H5216_078_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	078	2	1	04	01	H5216_078_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	078	2	1	04	01	H5216_078_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	078	2	1	04	01	H5216_078_2	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	078	2	1	04	01	H5216_078_2	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	078	2	1	04	01	H5216_078_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	078	2	1	04	01	H5216_078_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	078	2	1	04	01	H5216_078_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	081	0	1	04	01	H5216_081_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	081	0	1	04	01	H5216_081_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	081	0	1	04	01	H5216_081_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	081	0	1	04	01	H5216_081_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	081	0	1	04	01	H5216_081_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	083	0	1	04	01	H5216_083_0	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	8.00		24.00																									10.00		30.00				8.00		0.00				8.00				8.00		0.27				0.33	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				10.00		30.00	8.00		0.00	8.00		8.00
H5216	083	0	1	04	01	H5216_083_0	9			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	083	0	1	04	01	H5216_083_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	083	0	1	04	01	H5216_083_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	083	0	1	04	01	H5216_083_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	088	0	1	04	01	H5216_088_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	088	0	1	04	01	H5216_088_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	088	0	1	04	01	H5216_088_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	088	0	1	04	01	H5216_088_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	088	0	1	04	01	H5216_088_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	089	0	1	04	01	H5216_089_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	089	0	1	04	01	H5216_089_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	089	0	1	04	01	H5216_089_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	089	0	1	04	01	H5216_089_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	089	0	1	04	01	H5216_089_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	089	0	1	04	01	H5216_089_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	089	0	1	04	01	H5216_089_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	092	0	1	04	01	H5216_092_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	092	0	1	04	01	H5216_092_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	092	0	1	04	01	H5216_092_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	092	0	1	04	01	H5216_092_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				98.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	092	0	1	04	01	H5216_092_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	097	0	1	04	01	H5216_097_0	9			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	097	0	1	04	01	H5216_097_0	9			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	097	0	1	04	01	H5216_097_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	097	0	1	04	01	H5216_097_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	097	0	1	04	01	H5216_097_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	099	0	1	04	01	H5216_099_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	099	0	1	04	01	H5216_099_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	099	0	1	04	01	H5216_099_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	099	0	1	04	01	H5216_099_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	099	0	1	04	01	H5216_099_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	100	0	1	04	01	H5216_100_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	100	0	1	04	01	H5216_100_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	100	0	1	04	01	H5216_100_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	100	0	1	04	01	H5216_100_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	100	0	1	04	01	H5216_100_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	106	0	1	04	01	H5216_106_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	106	0	1	04	01	H5216_106_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	106	0	1	04	01	H5216_106_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	106	0	1	04	01	H5216_106_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	106	0	1	04	01	H5216_106_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	106	0	1	04	01	H5216_106_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	106	0	1	04	01	H5216_106_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	107	0	1	04	01	H5216_107_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	107	0	1	04	01	H5216_107_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	107	0	1	04	01	H5216_107_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	107	0	1	04	01	H5216_107_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	107	0	1	04	01	H5216_107_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	112	0	1	04	01	H5216_112_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	112	0	1	04	01	H5216_112_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	112	0	1	04	01	H5216_112_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	112	0	1	04	01	H5216_112_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	112	0	1	04	01	H5216_112_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	112	0	1	04	01	H5216_112_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	112	0	1	04	01	H5216_112_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	114	0	1	04	01	H5216_114_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	114	0	1	04	01	H5216_114_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	114	0	1	04	01	H5216_114_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	114	0	1	04	01	H5216_114_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	114	0	1	04	01	H5216_114_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	114	0	1	04	01	H5216_114_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	114	0	1	04	01	H5216_114_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	117	0	1	04	01	H5216_117_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	117	0	1	04	01	H5216_117_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	117	0	1	04	01	H5216_117_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	117	0	1	04	01	H5216_117_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	117	0	1	04	01	H5216_117_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	120	0	1	04	01	H5216_120_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	120	0	1	04	01	H5216_120_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	120	0	1	04	01	H5216_120_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	120	0	1	04	01	H5216_120_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	120	0	1	04	01	H5216_120_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	124	0	1	04	01	H5216_124_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	124	0	1	04	01	H5216_124_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	124	0	1	04	01	H5216_124_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	124	0	1	04	01	H5216_124_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	124	0	1	04	01	H5216_124_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	131	0	1	04	01	H5216_131_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	131	0	1	04	01	H5216_131_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	131	0	1	04	01	H5216_131_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	131	0	1	04	01	H5216_131_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	131	0	1	04	01	H5216_131_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	131	0	1	04	01	H5216_131_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	131	0	1	04	01	H5216_131_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	132	0	1	04	01	H5216_132_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	132	0	1	04	01	H5216_132_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	132	0	1	04	01	H5216_132_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	132	0	1	04	01	H5216_132_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	132	0	1	04	01	H5216_132_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	132	0	1	04	01	H5216_132_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	132	0	1	04	01	H5216_132_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	133	0	1	04	01	H5216_133_0	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	133	0	1	04	01	H5216_133_0	9			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	133	0	1	04	01	H5216_133_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	133	0	1	04	01	H5216_133_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	133	0	1	04	01	H5216_133_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	136	0	1	04	01	H5216_136_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	136	0	1	04	01	H5216_136_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	136	0	1	04	01	H5216_136_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	136	0	1	04	01	H5216_136_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	136	0	1	04	01	H5216_136_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	137	0	1	04	01	H5216_137_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	137	0	1	04	01	H5216_137_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5216	137	0	1	04	01	H5216_137_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	137	0	1	04	01	H5216_137_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	137	0	1	04	01	H5216_137_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	138	0	1	04	01	H5216_138_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	138	0	1	04	01	H5216_138_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	138	0	1	04	01	H5216_138_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	138	0	1	04	01	H5216_138_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	138	0	1	04	01	H5216_138_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	138	0	1	04	01	H5216_138_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	138	0	1	04	01	H5216_138_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	141	0	1	04	01	H5216_141_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	141	0	1	04	01	H5216_141_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	141	0	1	04	01	H5216_141_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	141	0	1	04	01	H5216_141_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	141	0	1	04	01	H5216_141_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	142	1	1	04	01	H5216_142_1	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	142	1	1	04	01	H5216_142_1	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	142	1	1	04	01	H5216_142_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	142	1	1	04	01	H5216_142_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	142	1	1	04	01	H5216_142_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	142	2	1	04	01	H5216_142_2	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	142	2	1	04	01	H5216_142_2	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	142	2	1	04	01	H5216_142_2	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	142	2	1	04	01	H5216_142_2	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	142	2	1	04	01	H5216_142_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	144	0	1	04	01	H5216_144_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	144	0	1	04	01	H5216_144_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	144	0	1	04	01	H5216_144_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	144	0	1	04	01	H5216_144_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	144	0	1	04	01	H5216_144_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	154	0	1	04	01	H5216_154_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	154	0	1	04	01	H5216_154_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	154	0	1	04	01	H5216_154_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	154	0	1	04	01	H5216_154_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	154	0	1	04	01	H5216_154_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	160	0	1	04	01	H5216_160_0	6			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									19.00		57.00				5.00		0.00				5.00				5.00		0.17				0.63	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				19.00		57.00	5.00		0.00	5.00		5.00
H5216	160	0	1	04	01	H5216_160_0	6			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	160	0	1	04	01	H5216_160_0	6			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				58.00	22		22																								25		25				22		22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	160	0	1	04	01	H5216_160_0	6			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				80.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	160	0	1	04	01	H5216_160_0	6			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	161	0	1	04	01	H5216_161_0	6			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
H5216	161	0	1	04	01	H5216_161_0	6			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	161	0	1	04	01	H5216_161_0	6			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	161	0	1	04	01	H5216_161_0	6			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	32		32																								32		32				32		32			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	161	0	1	04	01	H5216_161_0	6			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	168	0	1	04	01	H5216_168_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	168	0	1	04	01	H5216_168_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	168	0	1	04	01	H5216_168_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	168	0	1	04	01	H5216_168_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	168	0	1	04	01	H5216_168_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	169	0	1	04	01	H5216_169_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	169	0	1	04	01	H5216_169_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	169	0	1	04	01	H5216_169_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	169	0	1	04	01	H5216_169_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	169	0	1	04	01	H5216_169_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	170	0	1	04	01	H5216_170_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	170	0	1	04	01	H5216_170_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	170	0	1	04	01	H5216_170_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	170	0	1	04	01	H5216_170_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	170	0	1	04	01	H5216_170_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	171	0	1	04	01	H5216_171_0	5			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	8.00		24.00																									19.00		57.00				8.00		0.00				8.00				8.00		0.27				0.63	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				19.00		57.00	8.00		0.00	8.00		8.00
H5216	171	0	1	04	01	H5216_171_0	5			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	171	0	1	04	01	H5216_171_0	5			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	21		21																								21		21				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	171	0	1	04	01	H5216_171_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	171	0	1	04	01	H5216_171_0	5			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	172	0	1	04	01	H5216_172_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	172	0	1	04	01	H5216_172_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	172	0	1	04	01	H5216_172_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	172	0	1	04	01	H5216_172_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	172	0	1	04	01	H5216_172_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	172	0	1	04	01	H5216_172_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	172	0	1	04	01	H5216_172_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	173	0	1	04	01	H5216_173_0	5			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	173	0	1	04	01	H5216_173_0	5			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	14.00		42.00																									20.00		60.00				14.00		0.00				14.00				14.00		0.47				0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00		42.00				20.00		60.00	14.00		0.00	14.00		14.00
H5216	173	0	1	04	01	H5216_173_0	5			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	21		21																								25		25				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	173	0	1	04	01	H5216_173_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				59.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	173	0	1	04	01	H5216_173_0	5			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	175	0	1	04	01	H5216_175_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	175	0	1	04	01	H5216_175_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	175	0	1	04	01	H5216_175_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	175	0	1	04	01	H5216_175_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	175	0	1	04	01	H5216_175_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	175	0	1	04	01	H5216_175_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	175	0	1	04	01	H5216_175_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	176	0	1	04	01	H5216_176_0	5			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
H5216	176	0	1	04	01	H5216_176_0	5			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	176	0	1	04	01	H5216_176_0	5			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				37.00	19		19																								19		19				19		19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	176	0	1	04	01	H5216_176_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				56.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	176	0	1	04	01	H5216_176_0	5			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	177	0	1	04	01	H5216_177_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	177	0	1	04	01	H5216_177_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	177	0	1	04	01	H5216_177_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	177	0	1	04	01	H5216_177_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	177	0	1	04	01	H5216_177_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	177	0	1	04	01	H5216_177_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	177	0	1	04	01	H5216_177_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	179	0	1	04	01	H5216_179_0	5			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									19.00		57.00				7.00		0.00				7.00				7.00		0.23				0.63	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				19.00		57.00	7.00		0.00	7.00		7.00
H5216	179	0	1	04	01	H5216_179_0	5			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	179	0	1	04	01	H5216_179_0	5			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				47.00	21		21																								21		21				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	179	0	1	04	01	H5216_179_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				80.00	27		27																								27		27				27		27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	179	0	1	04	01	H5216_179_0	5			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	180	0	1	04	01	H5216_180_0	6			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
H5216	180	0	1	04	01	H5216_180_0	6			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	180	0	1	04	01	H5216_180_0	6			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	180	0	1	04	01	H5216_180_0	6			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				81.00	34		34																								34		34				34		34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	180	0	1	04	01	H5216_180_0	6			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	182	0	1	04	01	H5216_182_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	182	0	1	04	01	H5216_182_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	182	0	1	04	01	H5216_182_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	182	0	1	04	01	H5216_182_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	182	0	1	04	01	H5216_182_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	182	0	1	04	01	H5216_182_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	182	0	1	04	01	H5216_182_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	185	0	1	04	01	H5216_185_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	185	0	1	04	01	H5216_185_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	185	0	1	04	01	H5216_185_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	185	0	1	04	01	H5216_185_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	185	0	1	04	01	H5216_185_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	185	0	1	04	01	H5216_185_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	185	0	1	04	01	H5216_185_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	186	0	1	04	01	H5216_186_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	186	0	1	04	01	H5216_186_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	186	0	1	04	01	H5216_186_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	186	0	1	04	01	H5216_186_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	186	0	1	04	01	H5216_186_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	186	0	1	04	01	H5216_186_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	186	0	1	04	01	H5216_186_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	188	0	1	04	01	H5216_188_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	188	0	1	04	01	H5216_188_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	188	0	1	04	01	H5216_188_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	188	0	1	04	01	H5216_188_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	188	0	1	04	01	H5216_188_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	188	0	1	04	01	H5216_188_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	188	0	1	04	01	H5216_188_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	192	0	1	04	01	H5216_192_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	192	0	1	04	01	H5216_192_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	192	0	1	04	01	H5216_192_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	192	0	1	04	01	H5216_192_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	192	0	1	04	01	H5216_192_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	192	0	1	04	01	H5216_192_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	192	0	1	04	01	H5216_192_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	193	0	1	04	01	H5216_193_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	193	0	1	04	01	H5216_193_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	193	0	1	04	01	H5216_193_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	193	0	1	04	01	H5216_193_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	193	0	1	04	01	H5216_193_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	193	0	1	04	01	H5216_193_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	193	0	1	04	01	H5216_193_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	194	0	1	04	01	H5216_194_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	194	0	1	04	01	H5216_194_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	194	0	1	04	01	H5216_194_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	194	0	1	04	01	H5216_194_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	194	0	1	04	01	H5216_194_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	195	0	1	04	01	H5216_195_0	6			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	12.00		36.00																									19.00		57.00				12.00		0.00				12.00				12.00		0.40				0.63	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				19.00		57.00	12.00		0.00	12.00		12.00
H5216	195	0	1	04	01	H5216_195_0	6			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	18.00		54.00																									20.00		60.00				18.00		0.00				18.00				18.00		0.60				0.67	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				20.00		60.00	18.00		0.00	18.00		18.00
H5216	195	0	1	04	01	H5216_195_0	6			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	21		21																								25		25				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	195	0	1	04	01	H5216_195_0	6			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				66.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	195	0	1	04	01	H5216_195_0	6			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	196	1	1	04	01	H5216_196_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	196	1	1	04	01	H5216_196_1	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	196	1	1	04	01	H5216_196_1	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	196	1	1	04	01	H5216_196_1	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	196	1	1	04	01	H5216_196_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	196	1	1	04	01	H5216_196_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	196	1	1	04	01	H5216_196_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	196	2	1	04	01	H5216_196_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	196	2	1	04	01	H5216_196_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	196	2	1	04	01	H5216_196_2	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	196	2	1	04	01	H5216_196_2	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	196	2	1	04	01	H5216_196_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	196	2	1	04	01	H5216_196_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	196	2	1	04	01	H5216_196_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	197	0	1	04	01	H5216_197_0	7			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
H5216	197	0	1	04	01	H5216_197_0	7			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	19.00		57.00																									20.00		60.00				19.00		0.00				19.00				19.00		0.63				0.67	0.63	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00		57.00				20.00		60.00	19.00		0.00	19.00		19.00
H5216	197	0	1	04	01	H5216_197_0	7			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				49.00	21		21																								25		25				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	197	0	1	04	01	H5216_197_0	7			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				69.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	197	0	1	04	01	H5216_197_0	7			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	198	0	1	04	01	H5216_198_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	198	0	1	04	01	H5216_198_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	198	0	1	04	01	H5216_198_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	198	0	1	04	01	H5216_198_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	198	0	1	04	01	H5216_198_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	198	0	1	04	01	H5216_198_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	198	0	1	04	01	H5216_198_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	203	1	1	04	01	H5216_203_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	203	1	1	04	01	H5216_203_1	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	203	1	1	04	01	H5216_203_1	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	203	1	1	04	01	H5216_203_1	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	203	1	1	04	01	H5216_203_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	203	1	1	04	01	H5216_203_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	203	1	1	04	01	H5216_203_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	203	2	1	04	01	H5216_203_2	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	203	2	1	04	01	H5216_203_2	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	203	2	1	04	01	H5216_203_2	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	203	2	1	04	01	H5216_203_2	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	203	2	1	04	01	H5216_203_2	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	203	2	1	04	01	H5216_203_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	203	2	1	04	01	H5216_203_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	207	0	1	04	01	H5216_207_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	207	0	1	04	01	H5216_207_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	207	0	1	04	01	H5216_207_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	207	0	1	04	01	H5216_207_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	207	0	1	04	01	H5216_207_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	207	0	1	04	01	H5216_207_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	207	0	1	04	01	H5216_207_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	211	0	1	04	01	H5216_211_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	211	0	1	04	01	H5216_211_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	211	0	1	04	01	H5216_211_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	211	0	1	04	01	H5216_211_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	211	0	1	04	01	H5216_211_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	215	0	1	04	01	H5216_215_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	215	0	1	04	01	H5216_215_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	215	0	1	04	01	H5216_215_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	215	0	1	04	01	H5216_215_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	215	0	1	04	01	H5216_215_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	215	0	1	04	01	H5216_215_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	215	0	1	04	01	H5216_215_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	223	0	1	04	01	H5216_223_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	223	0	1	04	01	H5216_223_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	223	0	1	04	01	H5216_223_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	223	0	1	04	01	H5216_223_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	223	0	1	04	01	H5216_223_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	223	0	1	04	01	H5216_223_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	223	0	1	04	01	H5216_223_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	224	0	1	04	01	H5216_224_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	224	0	1	04	01	H5216_224_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	224	0	1	04	01	H5216_224_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	224	0	1	04	01	H5216_224_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	224	0	1	04	01	H5216_224_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	224	0	1	04	01	H5216_224_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	224	0	1	04	01	H5216_224_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	226	0	1	04	01	H5216_226_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	226	0	1	04	01	H5216_226_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	226	0	1	04	01	H5216_226_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	226	0	1	04	01	H5216_226_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	226	0	1	04	01	H5216_226_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	226	0	1	04	01	H5216_226_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	226	0	1	04	01	H5216_226_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	229	0	1	04	01	H5216_229_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	229	0	1	04	01	H5216_229_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	229	0	1	04	01	H5216_229_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	229	0	1	04	01	H5216_229_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	229	0	1	04	01	H5216_229_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	229	0	1	04	01	H5216_229_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	229	0	1	04	01	H5216_229_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	231	0	1	04	01	H5216_231_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	231	0	1	04	01	H5216_231_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	231	0	1	04	01	H5216_231_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	231	0	1	04	01	H5216_231_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	231	0	1	04	01	H5216_231_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	231	0	1	04	01	H5216_231_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	231	0	1	04	01	H5216_231_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	232	1	1	04	01	H5216_232_1	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	232	1	1	04	01	H5216_232_1	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	232	1	1	04	01	H5216_232_1	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	232	1	1	04	01	H5216_232_1	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	232	1	1	04	01	H5216_232_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	232	2	1	04	01	H5216_232_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	232	2	1	04	01	H5216_232_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	232	2	1	04	01	H5216_232_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	232	2	1	04	01	H5216_232_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	232	2	1	04	01	H5216_232_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	233	1	1	04	01	H5216_233_1	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	233	1	1	04	01	H5216_233_1	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	233	1	1	04	01	H5216_233_1	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	233	1	1	04	01	H5216_233_1	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	233	1	1	04	01	H5216_233_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	233	2	1	04	01	H5216_233_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	233	2	1	04	01	H5216_233_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	233	2	1	04	01	H5216_233_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	233	2	1	04	01	H5216_233_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	233	2	1	04	01	H5216_233_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	244	0	1	04	01	H5216_244_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	244	0	1	04	01	H5216_244_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5216	244	0	1	04	01	H5216_244_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	244	0	1	04	01	H5216_244_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5216	244	0	1	04	01	H5216_244_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	244	0	1	04	01	H5216_244_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	244	0	1	04	01	H5216_244_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5216	244	0	1	04	01	H5216_244_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5216	246	0	1	04	01	H5216_246_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	246	0	1	04	01	H5216_246_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5216	246	0	1	04	01	H5216_246_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	246	0	1	04	01	H5216_246_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5216	246	0	1	04	01	H5216_246_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	246	0	1	04	01	H5216_246_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	246	0	1	04	01	H5216_246_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5216	246	0	1	04	01	H5216_246_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5216	247	0	1	04	01	H5216_247_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	247	0	1	04	01	H5216_247_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	247	0	1	04	01	H5216_247_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	247	0	1	04	01	H5216_247_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	247	0	1	04	01	H5216_247_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	247	0	1	04	01	H5216_247_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	247	0	1	04	01	H5216_247_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	249	0	1	04	01	H5216_249_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	249	0	1	04	01	H5216_249_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	249	0	1	04	01	H5216_249_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	249	0	1	04	01	H5216_249_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	249	0	1	04	01	H5216_249_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	249	0	1	04	01	H5216_249_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	249	0	1	04	01	H5216_249_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	250	0	1	04	01	H5216_250_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	250	0	1	04	01	H5216_250_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	250	0	1	04	01	H5216_250_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	250	0	1	04	01	H5216_250_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	250	0	1	04	01	H5216_250_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	250	0	1	04	01	H5216_250_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	250	0	1	04	01	H5216_250_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	251	0	1	04	01	H5216_251_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	251	0	1	04	01	H5216_251_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	251	0	1	04	01	H5216_251_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	251	0	1	04	01	H5216_251_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	251	0	1	04	01	H5216_251_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	251	0	1	04	01	H5216_251_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	251	0	1	04	01	H5216_251_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	252	0	1	04	01	H5216_252_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	252	0	1	04	01	H5216_252_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	252	0	1	04	01	H5216_252_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	252	0	1	04	01	H5216_252_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	252	0	1	04	01	H5216_252_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	252	0	1	04	01	H5216_252_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	252	0	1	04	01	H5216_252_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	253	0	1	04	01	H5216_253_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	253	0	1	04	01	H5216_253_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	253	0	1	04	01	H5216_253_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	253	0	1	04	01	H5216_253_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	253	0	1	04	01	H5216_253_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	253	0	1	04	01	H5216_253_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	253	0	1	04	01	H5216_253_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	254	0	1	04	01	H5216_254_0	10			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	254	0	1	04	01	H5216_254_0	10			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	254	0	1	04	01	H5216_254_0	10			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	254	0	1	04	01	H5216_254_0	10			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	254	0	1	04	01	H5216_254_0	10			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	254	0	1	04	01	H5216_254_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	254	0	1	04	01	H5216_254_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	255	0	1	04	01	H5216_255_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	255	0	1	04	01	H5216_255_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	255	0	1	04	01	H5216_255_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	255	0	1	04	01	H5216_255_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	255	0	1	04	01	H5216_255_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	255	0	1	04	01	H5216_255_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	255	0	1	04	01	H5216_255_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	260	0	1	04	01	H5216_260_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	260	0	1	04	01	H5216_260_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	260	0	1	04	01	H5216_260_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	260	0	1	04	01	H5216_260_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	260	0	1	04	01	H5216_260_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	261	0	1	04	01	H5216_261_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	261	0	1	04	01	H5216_261_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	261	0	1	04	01	H5216_261_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H5216	261	0	1	04	01	H5216_261_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	261	0	1	04	01	H5216_261_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	261	0	1	04	01	H5216_261_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	261	0	1	04	01	H5216_261_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	263	0	1	04	01	H5216_263_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	263	0	1	04	01	H5216_263_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	263	0	1	04	01	H5216_263_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	263	0	1	04	01	H5216_263_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	263	0	1	04	01	H5216_263_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	263	0	1	04	01	H5216_263_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		190.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	263	0	1	04	01	H5216_263_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	264	0	1	04	01	H5216_264_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	264	0	1	04	01	H5216_264_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	264	0	1	04	01	H5216_264_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	264	0	1	04	01	H5216_264_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	264	0	1	04	01	H5216_264_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	264	0	1	04	01	H5216_264_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	264	0	1	04	01	H5216_264_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	265	0	1	04	01	H5216_265_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	265	0	1	04	01	H5216_265_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	265	0	1	04	01	H5216_265_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	265	0	1	04	01	H5216_265_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	265	0	1	04	01	H5216_265_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	265	0	1	04	01	H5216_265_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	265	0	1	04	01	H5216_265_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	266	0	1	04	01	H5216_266_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	266	0	1	04	01	H5216_266_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	266	0	1	04	01	H5216_266_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	266	0	1	04	01	H5216_266_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	266	0	1	04	01	H5216_266_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	269	0	1	04	01	H5216_269_0	12			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	269	0	1	04	01	H5216_269_0	12			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	269	0	1	04	01	H5216_269_0	12			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	269	0	1	04	01	H5216_269_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	269	0	1	04	01	H5216_269_0	12			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	271	0	1	04	01	H5216_271_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	271	0	1	04	01	H5216_271_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	271	0	1	04	01	H5216_271_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	271	0	1	04	01	H5216_271_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	271	0	1	04	01	H5216_271_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	273	0	1	04	01	H5216_273_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	273	0	1	04	01	H5216_273_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	273	0	1	04	01	H5216_273_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	273	0	1	04	01	H5216_273_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	273	0	1	04	01	H5216_273_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	273	0	1	04	01	H5216_273_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	273	0	1	04	01	H5216_273_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	274	0	1	04	01	H5216_274_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	274	0	1	04	01	H5216_274_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	274	0	1	04	01	H5216_274_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	274	0	1	04	01	H5216_274_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	274	0	1	04	01	H5216_274_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	275	0	1	04	01	H5216_275_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	275	0	1	04	01	H5216_275_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	275	0	1	04	01	H5216_275_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	275	0	1	04	01	H5216_275_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	275	0	1	04	01	H5216_275_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	275	0	1	04	01	H5216_275_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	275	0	1	04	01	H5216_275_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	279	0	1	04	01	H5216_279_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	279	0	1	04	01	H5216_279_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	279	0	1	04	01	H5216_279_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	279	0	1	04	01	H5216_279_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	279	0	1	04	01	H5216_279_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	279	0	1	04	01	H5216_279_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	279	0	1	04	01	H5216_279_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	280	1	1	04	01	H5216_280_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H5216	280	1	1	04	01	H5216_280_1	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	280	1	1	04	01	H5216_280_1	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	280	1	1	04	01	H5216_280_1	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	280	1	1	04	01	H5216_280_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	280	1	1	04	01	H5216_280_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	280	1	1	04	01	H5216_280_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	280	2	1	04	01	H5216_280_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H5216	280	2	1	04	01	H5216_280_2	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	280	2	1	04	01	H5216_280_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	280	2	1	04	01	H5216_280_2	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	280	2	1	04	01	H5216_280_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	280	2	1	04	01	H5216_280_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	280	2	1	04	01	H5216_280_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	281	0	1	04	01	H5216_281_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	281	0	1	04	01	H5216_281_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	281	0	1	04	01	H5216_281_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	281	0	1	04	01	H5216_281_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	281	0	1	04	01	H5216_281_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	281	0	1	04	01	H5216_281_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	281	0	1	04	01	H5216_281_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	283	0	1	04	01	H5216_283_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	283	0	1	04	01	H5216_283_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	283	0	1	04	01	H5216_283_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	283	0	1	04	01	H5216_283_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	283	0	1	04	01	H5216_283_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	283	0	1	04	01	H5216_283_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	283	0	1	04	01	H5216_283_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				35.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	284	0	1	04	01	H5216_284_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H5216	284	0	1	04	01	H5216_284_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	284	0	1	04	01	H5216_284_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	284	0	1	04	01	H5216_284_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	284	0	1	04	01	H5216_284_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	284	0	1	04	01	H5216_284_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	284	0	1	04	01	H5216_284_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	285	0	1	04	01	H5216_285_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	285	0	1	04	01	H5216_285_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	285	0	1	04	01	H5216_285_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	285	0	1	04	01	H5216_285_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	285	0	1	04	01	H5216_285_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	285	0	1	04	01	H5216_285_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	285	0	1	04	01	H5216_285_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	287	0	1	04	01	H5216_287_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	287	0	1	04	01	H5216_287_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	287	0	1	04	01	H5216_287_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	287	0	1	04	01	H5216_287_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	287	0	1	04	01	H5216_287_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	287	0	1	04	01	H5216_287_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	287	0	1	04	01	H5216_287_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	288	0	1	04	01	H5216_288_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	288	0	1	04	01	H5216_288_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	288	0	1	04	01	H5216_288_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	288	0	1	04	01	H5216_288_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	288	0	1	04	01	H5216_288_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	288	0	1	04	01	H5216_288_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	288	0	1	04	01	H5216_288_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	289	0	1	04	01	H5216_289_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	289	0	1	04	01	H5216_289_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	289	0	1	04	01	H5216_289_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	289	0	1	04	01	H5216_289_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	289	0	1	04	01	H5216_289_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	289	0	1	04	01	H5216_289_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	289	0	1	04	01	H5216_289_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	293	0	1	04	01	H5216_293_0	9			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	8.00		24.00																									10.00		30.00				8.00		0.00				8.00				8.00		0.27				0.33	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				10.00		30.00	8.00		0.00	8.00		8.00
H5216	293	0	1	04	01	H5216_293_0	9			Generic	3	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	18.00		54.00																									20.00		60.00				18.00		0.00				18.00				18.00		0.60				0.67	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				20.00		60.00	18.00		0.00	18.00		18.00
H5216	293	0	1	04	01	H5216_293_0	9			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				46.00	22		22																								25		25				22		22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	293	0	1	04	01	H5216_293_0	9			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	293	0	1	04	01	H5216_293_0	9			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	294	0	1	04	01	H5216_294_0	4			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	10.00		30.00																									19.00		57.00				10.00		0.00				10.00				10.00		0.33				0.63	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				19.00		57.00	10.00		0.00	10.00		10.00
H5216	294	0	1	04	01	H5216_294_0	4			Generic	3	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	294	0	1	04	01	H5216_294_0	4			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				45.00	21		21																								25		25				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	294	0	1	04	01	H5216_294_0	4			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				64.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	294	0	1	04	01	H5216_294_0	4			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	300	0	1	04	01	H5216_300_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									15.00		45.00				0.00		0.00				0.00				0.00		0.00				0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				15.00		45.00	0.00		0.00	0.00		0.00
H5216	300	0	1	04	01	H5216_300_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	300	0	1	04	01	H5216_300_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	300	0	1	04	01	H5216_300_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	300	0	1	04	01	H5216_300_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	304	0	1	04	01	H5216_304_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	304	0	1	04	01	H5216_304_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	304	0	1	04	01	H5216_304_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	304	0	1	04	01	H5216_304_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	304	0	1	04	01	H5216_304_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	304	0	1	04	01	H5216_304_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	304	0	1	04	01	H5216_304_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	305	0	1	04	01	H5216_305_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	305	0	1	04	01	H5216_305_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	305	0	1	04	01	H5216_305_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	305	0	1	04	01	H5216_305_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	305	0	1	04	01	H5216_305_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	305	0	1	04	01	H5216_305_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	305	0	1	04	01	H5216_305_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	306	0	1	04	01	H5216_306_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	306	0	1	04	01	H5216_306_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	306	0	1	04	01	H5216_306_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	306	0	1	04	01	H5216_306_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	306	0	1	04	01	H5216_306_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	306	0	1	04	01	H5216_306_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	306	0	1	04	01	H5216_306_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	307	0	1	04	01	H5216_307_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	307	0	1	04	01	H5216_307_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	307	0	1	04	01	H5216_307_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	307	0	1	04	01	H5216_307_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	307	0	1	04	01	H5216_307_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	307	0	1	04	01	H5216_307_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	307	0	1	04	01	H5216_307_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	308	0	1	04	01	H5216_308_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	308	0	1	04	01	H5216_308_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	308	0	1	04	01	H5216_308_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	308	0	1	04	01	H5216_308_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	308	0	1	04	01	H5216_308_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	309	0	1	04	01	H5216_309_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	309	0	1	04	01	H5216_309_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	309	0	1	04	01	H5216_309_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	309	0	1	04	01	H5216_309_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	309	0	1	04	01	H5216_309_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	309	0	1	04	01	H5216_309_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	309	0	1	04	01	H5216_309_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	311	0	1	04	01	H5216_311_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	311	0	1	04	01	H5216_311_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	311	0	1	04	01	H5216_311_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	311	0	1	04	01	H5216_311_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	311	0	1	04	01	H5216_311_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	312	0	1	04	01	H5216_312_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	312	0	1	04	01	H5216_312_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	312	0	1	04	01	H5216_312_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	312	0	1	04	01	H5216_312_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	312	0	1	04	01	H5216_312_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	313	0	1	04	01	H5216_313_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	313	0	1	04	01	H5216_313_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	313	0	1	04	01	H5216_313_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	313	0	1	04	01	H5216_313_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	313	0	1	04	01	H5216_313_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	313	0	1	04	01	H5216_313_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	95.00		285.00																									100.00		300.00				95.00		190.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	313	0	1	04	01	H5216_313_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	314	0	1	04	01	H5216_314_0	10			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	314	0	1	04	01	H5216_314_0	10			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	314	0	1	04	01	H5216_314_0	10			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	314	0	1	04	01	H5216_314_0	10			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	314	0	1	04	01	H5216_314_0	10			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	314	0	1	04	01	H5216_314_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	314	0	1	04	01	H5216_314_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	316	1	1	04	01	H5216_316_1	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	316	1	1	04	01	H5216_316_1	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	316	1	1	04	01	H5216_316_1	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	316	1	1	04	01	H5216_316_1	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	316	1	1	04	01	H5216_316_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	316	1	1	04	01	H5216_316_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	316	1	1	04	01	H5216_316_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	316	3	1	04	01	H5216_316_3	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	316	3	1	04	01	H5216_316_3	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	316	3	1	04	01	H5216_316_3	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	316	3	1	04	01	H5216_316_3	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	316	3	1	04	01	H5216_316_3	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	316	3	1	04	01	H5216_316_3	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	316	3	1	04	01	H5216_316_3	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	317	0	1	04	01	H5216_317_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	317	0	1	04	01	H5216_317_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	317	0	1	04	01	H5216_317_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	317	0	1	04	01	H5216_317_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	317	0	1	04	01	H5216_317_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	317	0	1	04	01	H5216_317_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	317	0	1	04	01	H5216_317_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	318	1	1	04	01	H5216_318_1	10			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	318	1	1	04	01	H5216_318_1	10			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	318	1	1	04	01	H5216_318_1	10			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	318	1	1	04	01	H5216_318_1	10			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	318	1	1	04	01	H5216_318_1	10			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	318	1	1	04	01	H5216_318_1	10			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	318	1	1	04	01	H5216_318_1	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	318	2	1	04	01	H5216_318_2	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	318	2	1	04	01	H5216_318_2	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	318	2	1	04	01	H5216_318_2	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	318	2	1	04	01	H5216_318_2	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	318	2	1	04	01	H5216_318_2	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	318	2	1	04	01	H5216_318_2	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	318	2	1	04	01	H5216_318_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	318	3	1	04	01	H5216_318_3	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	318	3	1	04	01	H5216_318_3	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	318	3	1	04	01	H5216_318_3	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	318	3	1	04	01	H5216_318_3	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	318	3	1	04	01	H5216_318_3	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	318	3	1	04	01	H5216_318_3	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	318	3	1	04	01	H5216_318_3	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	319	0	1	04	01	H5216_319_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	319	0	1	04	01	H5216_319_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	319	0	1	04	01	H5216_319_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	319	0	1	04	01	H5216_319_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	319	0	1	04	01	H5216_319_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	319	0	1	04	01	H5216_319_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	319	0	1	04	01	H5216_319_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	320	0	1	04	01	H5216_320_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	320	0	1	04	01	H5216_320_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	320	0	1	04	01	H5216_320_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	320	0	1	04	01	H5216_320_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	320	0	1	04	01	H5216_320_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	320	0	1	04	01	H5216_320_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	320	0	1	04	01	H5216_320_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	322	0	1	04	01	H5216_322_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	322	0	1	04	01	H5216_322_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	322	0	1	04	01	H5216_322_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	322	0	1	04	01	H5216_322_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	322	0	1	04	01	H5216_322_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	322	0	1	04	01	H5216_322_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	322	0	1	04	01	H5216_322_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	324	0	1	04	01	H5216_324_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	324	0	1	04	01	H5216_324_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	324	0	1	04	01	H5216_324_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	324	0	1	04	01	H5216_324_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	324	0	1	04	01	H5216_324_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	324	0	1	04	01	H5216_324_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	324	0	1	04	01	H5216_324_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	325	0	1	04	01	H5216_325_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	325	0	1	04	01	H5216_325_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	325	0	1	04	01	H5216_325_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	325	0	1	04	01	H5216_325_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	325	0	1	04	01	H5216_325_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	326	0	1	04	01	H5216_326_0	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	326	0	1	04	01	H5216_326_0	9			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	326	0	1	04	01	H5216_326_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	326	0	1	04	01	H5216_326_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	326	0	1	04	01	H5216_326_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	327	0	1	04	01	H5216_327_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	327	0	1	04	01	H5216_327_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	327	0	1	04	01	H5216_327_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	327	0	1	04	01	H5216_327_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	327	0	1	04	01	H5216_327_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	327	0	1	04	01	H5216_327_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	327	0	1	04	01	H5216_327_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	328	0	1	04	01	H5216_328_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	328	0	1	04	01	H5216_328_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	328	0	1	04	01	H5216_328_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	328	0	1	04	01	H5216_328_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	328	0	1	04	01	H5216_328_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	328	0	1	04	01	H5216_328_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	328	0	1	04	01	H5216_328_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	333	0	1	04	01	H5216_333_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	333	0	1	04	01	H5216_333_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	333	0	1	04	01	H5216_333_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H5216	333	0	1	04	01	H5216_333_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	333	0	1	04	01	H5216_333_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	333	0	1	04	01	H5216_333_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	333	0	1	04	01	H5216_333_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	334	0	1	04	01	H5216_334_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	334	0	1	04	01	H5216_334_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H5216	334	0	1	04	01	H5216_334_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	334	0	1	04	01	H5216_334_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3	3															
H5216	334	0	1	04	01	H5216_334_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	334	0	1	04	01	H5216_334_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H5216	334	0	1	04	01	H5216_334_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	334	0	1	04	01	H5216_334_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H5216	334	0	1	04	01	H5216_334_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5216	334	0	1	04	01	H5216_334_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	3																
H5216	334	0	1	04	01	H5216_334_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5216	334	0	1	04	01	H5216_334_0	6			Select Care Drugs	4	11	1	2	6	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5216	335	0	1	04	01	H5216_335_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	335	0	1	04	01	H5216_335_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	335	0	1	04	01	H5216_335_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H5216	335	0	1	04	01	H5216_335_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	335	0	1	04	01	H5216_335_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	335	0	1	04	01	H5216_335_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	335	0	1	04	01	H5216_335_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	337	1	1	04	01	H5216_337_1	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	337	1	1	04	01	H5216_337_1	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	337	1	1	04	01	H5216_337_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	337	1	1	04	01	H5216_337_1	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	337	1	1	04	01	H5216_337_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	337	1	1	04	01	H5216_337_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	337	1	1	04	01	H5216_337_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	337	2	1	04	01	H5216_337_2	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	337	2	1	04	01	H5216_337_2	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	337	2	1	04	01	H5216_337_2	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	337	2	1	04	01	H5216_337_2	8			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	337	2	1	04	01	H5216_337_2	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	337	2	1	04	01	H5216_337_2	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	337	2	1	04	01	H5216_337_2	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	337	3	1	04	01	H5216_337_3	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	337	3	1	04	01	H5216_337_3	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	337	3	1	04	01	H5216_337_3	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	337	3	1	04	01	H5216_337_3	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	337	3	1	04	01	H5216_337_3	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	337	3	1	04	01	H5216_337_3	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	337	3	1	04	01	H5216_337_3	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	338	0	1	04	01	H5216_338_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	338	0	1	04	01	H5216_338_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	338	0	1	04	01	H5216_338_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	338	0	1	04	01	H5216_338_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	338	0	1	04	01	H5216_338_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	338	0	1	04	01	H5216_338_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	338	0	1	04	01	H5216_338_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	339	0	1	04	01	H5216_339_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	339	0	1	04	01	H5216_339_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	339	0	1	04	01	H5216_339_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	339	0	1	04	01	H5216_339_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	339	0	1	04	01	H5216_339_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	339	0	1	04	01	H5216_339_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	339	0	1	04	01	H5216_339_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	340	0	1	04	01	H5216_340_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	340	0	1	04	01	H5216_340_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	340	0	1	04	01	H5216_340_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5216	340	0	1	04	01	H5216_340_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	340	0	1	04	01	H5216_340_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	340	0	1	04	01	H5216_340_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	340	0	1	04	01	H5216_340_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	341	0	1	04	01	H5216_341_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	341	0	1	04	01	H5216_341_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	341	0	1	04	01	H5216_341_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5216	341	0	1	04	01	H5216_341_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	341	0	1	04	01	H5216_341_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	341	0	1	04	01	H5216_341_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	341	0	1	04	01	H5216_341_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	345	0	1	04	01	H5216_345_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	345	0	1	04	01	H5216_345_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	345	0	1	04	01	H5216_345_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	345	0	1	04	01	H5216_345_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	345	0	1	04	01	H5216_345_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	345	0	1	04	01	H5216_345_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	345	0	1	04	01	H5216_345_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	346	0	1	04	01	H5216_346_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	346	0	1	04	01	H5216_346_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	346	0	1	04	01	H5216_346_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	346	0	1	04	01	H5216_346_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	346	0	1	04	01	H5216_346_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	347	0	1	04	01	H5216_347_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	347	0	1	04	01	H5216_347_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	347	0	1	04	01	H5216_347_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	347	0	1	04	01	H5216_347_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	347	0	1	04	01	H5216_347_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	347	0	1	04	01	H5216_347_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	347	0	1	04	01	H5216_347_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	349	0	1	04	01	H5216_349_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	349	0	1	04	01	H5216_349_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	349	0	1	04	01	H5216_349_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	349	0	1	04	01	H5216_349_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	349	0	1	04	01	H5216_349_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	349	0	1	04	01	H5216_349_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	349	0	1	04	01	H5216_349_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	350	0	1	04	01	H5216_350_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	350	0	1	04	01	H5216_350_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	350	0	1	04	01	H5216_350_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	350	0	1	04	01	H5216_350_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	350	0	1	04	01	H5216_350_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	350	0	1	04	01	H5216_350_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	350	0	1	04	01	H5216_350_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	351	0	1	04	01	H5216_351_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	351	0	1	04	01	H5216_351_0	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	351	0	1	04	01	H5216_351_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	351	0	1	04	01	H5216_351_0	8			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	351	0	1	04	01	H5216_351_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	351	0	1	04	01	H5216_351_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	351	0	1	04	01	H5216_351_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	352	0	1	04	01	H5216_352_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	352	0	1	04	01	H5216_352_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	352	0	1	04	01	H5216_352_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	352	0	1	04	01	H5216_352_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	352	0	1	04	01	H5216_352_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	352	0	1	04	01	H5216_352_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	352	0	1	04	01	H5216_352_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	353	0	1	04	01	H5216_353_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	353	0	1	04	01	H5216_353_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	353	0	1	04	01	H5216_353_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	353	0	1	04	01	H5216_353_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	353	0	1	04	01	H5216_353_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	353	0	1	04	01	H5216_353_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	353	0	1	04	01	H5216_353_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	356	0	1	04	01	H5216_356_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	356	0	1	04	01	H5216_356_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	356	0	1	04	01	H5216_356_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	356	0	1	04	01	H5216_356_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	356	0	1	04	01	H5216_356_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	356	0	1	04	01	H5216_356_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	356	0	1	04	01	H5216_356_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	357	0	1	04	01	H5216_357_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5216	357	0	1	04	01	H5216_357_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	357	0	1	04	01	H5216_357_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	357	0	1	04	01	H5216_357_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	357	0	1	04	01	H5216_357_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	357	0	1	04	01	H5216_357_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	357	0	1	04	01	H5216_357_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	358	0	1	04	01	H5216_358_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	358	0	1	04	01	H5216_358_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	358	0	1	04	01	H5216_358_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	358	0	1	04	01	H5216_358_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	358	0	1	04	01	H5216_358_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	358	0	1	04	01	H5216_358_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	358	0	1	04	01	H5216_358_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	359	0	1	04	01	H5216_359_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5216	359	0	1	04	01	H5216_359_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	359	0	1	04	01	H5216_359_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	359	0	1	04	01	H5216_359_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	359	0	1	04	01	H5216_359_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	360	0	1	04	01	H5216_360_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	360	0	1	04	01	H5216_360_0	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	360	0	1	04	01	H5216_360_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	360	0	1	04	01	H5216_360_0	8			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	360	0	1	04	01	H5216_360_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H5216	360	0	1	04	01	H5216_360_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		198.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	360	0	1	04	01	H5216_360_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	363	0	1	04	01	H5216_363_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H5216	363	0	1	04	01	H5216_363_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	363	0	1	04	01	H5216_363_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	363	0	1	04	01	H5216_363_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	363	0	1	04	01	H5216_363_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	363	0	1	04	01	H5216_363_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	363	0	1	04	01	H5216_363_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	364	0	1	04	01	H5216_364_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	364	0	1	04	01	H5216_364_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	364	0	1	04	01	H5216_364_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5216	364	0	1	04	01	H5216_364_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	364	0	1	04	01	H5216_364_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	364	0	1	04	01	H5216_364_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	364	0	1	04	01	H5216_364_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	365	0	1	04	01	H5216_365_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	365	0	1	04	01	H5216_365_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	365	0	1	04	01	H5216_365_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	365	0	1	04	01	H5216_365_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	365	0	1	04	01	H5216_365_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	365	0	1	04	01	H5216_365_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	365	0	1	04	01	H5216_365_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	366	0	1	04	01	H5216_366_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	366	0	1	04	01	H5216_366_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	366	0	1	04	01	H5216_366_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	366	0	1	04	01	H5216_366_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	366	0	1	04	01	H5216_366_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	366	0	1	04	01	H5216_366_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	366	0	1	04	01	H5216_366_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	368	0	1	04	01	H5216_368_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	368	0	1	04	01	H5216_368_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	368	0	1	04	01	H5216_368_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	368	0	1	04	01	H5216_368_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	368	0	1	04	01	H5216_368_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	371	0	1	04	01	H5216_371_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	371	0	1	04	01	H5216_371_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H5216	371	0	1	04	01	H5216_371_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5216	371	0	1	04	01	H5216_371_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	371	0	1	04	01	H5216_371_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	372	0	1	04	01	H5216_372_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	372	0	1	04	01	H5216_372_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	372	0	1	04	01	H5216_372_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	372	0	1	04	01	H5216_372_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	372	0	1	04	01	H5216_372_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	372	0	1	04	01	H5216_372_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	372	0	1	04	01	H5216_372_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	375	0	1	04	01	H5216_375_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	375	0	1	04	01	H5216_375_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5216	375	0	1	04	01	H5216_375_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	375	0	1	04	01	H5216_375_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5216	375	0	1	04	01	H5216_375_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	375	0	1	04	01	H5216_375_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	375	0	1	04	01	H5216_375_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5216	375	0	1	04	01	H5216_375_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									11.00		33.00				0.00		0.00				0.00				0.00		0.00				0.37	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				11.00		33.00	0.00		0.00	0.00		0.00
H5216	376	0	1	04	01	H5216_376_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5216	376	0	1	04	01	H5216_376_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5216	376	0	1	04	01	H5216_376_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	376	0	1	04	01	H5216_376_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	376	0	1	04	01	H5216_376_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	378	0	1	04	01	H5216_378_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	378	0	1	04	01	H5216_378_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	378	0	1	04	01	H5216_378_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	378	0	1	04	01	H5216_378_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	378	0	1	04	01	H5216_378_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	378	0	1	04	01	H5216_378_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	378	0	1	04	01	H5216_378_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	380	0	1	04	01	H5216_380_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	380	0	1	04	01	H5216_380_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5216	380	0	1	04	01	H5216_380_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	380	0	1	04	01	H5216_380_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	380	0	1	04	01	H5216_380_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	382	0	1	04	01	H5216_382_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5216	382	0	1	04	01	H5216_382_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	382	0	1	04	01	H5216_382_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	382	0	1	04	01	H5216_382_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	382	0	1	04	01	H5216_382_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	383	0	1	04	01	H5216_383_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5216	383	0	1	04	01	H5216_383_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	383	0	1	04	01	H5216_383_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5216	383	0	1	04	01	H5216_383_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	383	0	1	04	01	H5216_383_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	383	0	1	04	01	H5216_383_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	383	0	1	04	01	H5216_383_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	384	0	1	04	01	H5216_384_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	384	0	1	04	01	H5216_384_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	384	0	1	04	01	H5216_384_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	384	0	1	04	01	H5216_384_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	384	0	1	04	01	H5216_384_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	384	0	1	04	01	H5216_384_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	384	0	1	04	01	H5216_384_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	387	1	1	04	01	H5216_387_1	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	387	1	1	04	01	H5216_387_1	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	387	1	1	04	01	H5216_387_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	387	1	1	04	01	H5216_387_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	387	1	1	04	01	H5216_387_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	387	2	1	04	01	H5216_387_2	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	387	2	1	04	01	H5216_387_2	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	387	2	1	04	01	H5216_387_2	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	387	2	1	04	01	H5216_387_2	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	387	2	1	04	01	H5216_387_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	389	0	1	04	01	H5216_389_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	3.00		9.00																									10.00		30.00				3.00		0.00				3.00				3.00		0.10				0.33	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		9.00				10.00		30.00	3.00		0.00	3.00		3.00
H5216	389	0	1	04	01	H5216_389_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5216	389	0	1	04	01	H5216_389_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	389	0	1	04	01	H5216_389_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	389	0	1	04	01	H5216_389_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	390	0	1	04	01	H5216_390_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	390	0	1	04	01	H5216_390_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	390	0	1	04	01	H5216_390_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	390	0	1	04	01	H5216_390_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	390	0	1	04	01	H5216_390_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	391	0	1	04	01	H5216_391_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	391	0	1	04	01	H5216_391_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	391	0	1	04	01	H5216_391_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	391	0	1	04	01	H5216_391_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	391	0	1	04	01	H5216_391_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	391	0	1	04	01	H5216_391_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	391	0	1	04	01	H5216_391_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	392	0	1	04	01	H5216_392_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	392	0	1	04	01	H5216_392_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5216	392	0	1	04	01	H5216_392_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H5216	392	0	1	04	01	H5216_392_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	392	0	1	04	01	H5216_392_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	393	0	1	04	01	H5216_393_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	393	0	1	04	01	H5216_393_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	393	0	1	04	01	H5216_393_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	393	0	1	04	01	H5216_393_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	393	0	1	04	01	H5216_393_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	395	0	1	04	01	H5216_395_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5216	395	0	1	04	01	H5216_395_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5216	395	0	1	04	01	H5216_395_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	395	0	1	04	01	H5216_395_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	395	0	1	04	01	H5216_395_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	396	0	1	04	01	H5216_396_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	396	0	1	04	01	H5216_396_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	396	0	1	04	01	H5216_396_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	396	0	1	04	01	H5216_396_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5216	396	0	1	04	01	H5216_396_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	396	0	1	04	01	H5216_396_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	396	0	1	04	01	H5216_396_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	397	0	1	04	01	H5216_397_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	397	0	1	04	01	H5216_397_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	397	0	1	04	01	H5216_397_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	397	0	1	04	01	H5216_397_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	397	0	1	04	01	H5216_397_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	397	0	1	04	01	H5216_397_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	397	0	1	04	01	H5216_397_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	398	0	1	04	01	H5216_398_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	398	0	1	04	01	H5216_398_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	398	0	1	04	01	H5216_398_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	398	0	1	04	01	H5216_398_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	398	0	1	04	01	H5216_398_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	398	0	1	04	01	H5216_398_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	398	0	1	04	01	H5216_398_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5216	399	0	1	04	01	H5216_399_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5216	399	0	1	04	01	H5216_399_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	399	0	1	04	01	H5216_399_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5216	399	0	1	04	01	H5216_399_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5216	399	0	1	04	01	H5216_399_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	399	0	1	04	01	H5216_399_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5216	399	0	1	04	01	H5216_399_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5232	001	0	1	04	01	H5232_001_0	9			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5232	001	0	1	04	01	H5232_001_0	9			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5232	001	0	1	04	01	H5232_001_0	9			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5232	001	0	1	04	01	H5232_001_0	9			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5232	001	0	1	04	01	H5232_001_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5232	001	0	1	04	01	H5232_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5232	001	0	1	04	01	H5232_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1091.93	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H5244	001	0	1	01	01	H5244_001_0	7			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	001	0	1	01	01	H5244_001_0	7			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5244	001	0	1	01	01	H5244_001_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	001	0	1	01	01	H5244_001_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5244	001	0	1	01	01	H5244_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	37.00	74.00	91.00																			37.00	74.00	91.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00	50.00	55.00				25.00	50.00	55.00				25.00		25.00
H5244	001	0	1	01	01	H5244_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	265.00																			95.00	190.00	265.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	001	0	1	01	01	H5244_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	001	0	1	01	01	H5244_001_0	7			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	22.00	33.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	002	0	1	01	01	H5244_002_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	002	0	1	01	01	H5244_002_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5244	002	0	1	01	01	H5244_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	002	0	1	01	01	H5244_002_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5244	002	0	1	01	01	H5244_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	37.00	74.00	91.00																			37.00	74.00	91.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5244	002	0	1	01	01	H5244_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	265.00																			95.00	190.00	265.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	002	0	1	01	01	H5244_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	002	0	1	01	01	H5244_002_0	7			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	003	0	1	01	01	H5244_003_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	003	0	1	01	01	H5244_003_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5244	003	0	1	01	01	H5244_003_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	003	0	1	01	01	H5244_003_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5244	003	0	1	01	01	H5244_003_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	37.00	74.00	91.00																			37.00	74.00	91.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00	50.00	55.00				25.00	50.00	55.00				25.00		25.00
H5244	003	0	1	01	01	H5244_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	265.00																			95.00	190.00	265.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	003	0	1	01	01	H5244_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5244	003	0	1	01	01	H5244_003_0	7			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5253	004	0	1	02	01	H5253_004_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	004	0	1	02	01	H5253_004_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	004	0	1	02	01	H5253_004_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	004	0	1	02	01	H5253_004_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	004	0	1	02	01	H5253_004_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	004	0	1	02	01	H5253_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	004	0	1	02	01	H5253_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				447.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	011	0	1	02	01	H5253_011_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	011	0	1	02	01	H5253_011_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	011	0	1	02	01	H5253_011_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	011	0	1	02	01	H5253_011_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	011	0	1	02	01	H5253_011_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	011	0	1	02	01	H5253_011_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	011	0	1	02	01	H5253_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	030	0	1	02	01	H5253_030_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	030	0	1	02	01	H5253_030_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	030	0	1	02	01	H5253_030_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	030	0	1	02	01	H5253_030_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	030	0	1	02	01	H5253_030_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	030	0	1	02	01	H5253_030_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	030	0	1	02	01	H5253_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				425.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	033	0	1	02	01	H5253_033_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	033	0	1	02	01	H5253_033_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	033	0	1	02	01	H5253_033_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	033	0	1	02	01	H5253_033_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	033	0	1	02	01	H5253_033_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	033	0	1	02	01	H5253_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	033	0	1	02	01	H5253_033_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				460.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	034	0	1	02	01	H5253_034_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	034	0	1	02	01	H5253_034_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	034	0	1	02	01	H5253_034_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	034	0	1	02	01	H5253_034_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	034	0	1	02	01	H5253_034_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	034	0	1	02	01	H5253_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	034	0	1	02	01	H5253_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				329.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	035	0	1	02	01	H5253_035_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	035	0	1	02	01	H5253_035_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	035	0	1	02	01	H5253_035_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	035	0	1	02	01	H5253_035_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	035	0	1	02	01	H5253_035_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	035	0	1	02	01	H5253_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	035	0	1	02	01	H5253_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				471.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	036	0	1	02	01	H5253_036_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	036	0	1	02	01	H5253_036_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	036	0	1	02	01	H5253_036_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	036	0	1	02	01	H5253_036_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	036	0	1	02	01	H5253_036_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	036	0	1	02	01	H5253_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	036	0	1	02	01	H5253_036_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				456.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	037	0	1	02	01	H5253_037_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	037	0	1	02	01	H5253_037_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	037	0	1	02	01	H5253_037_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	037	0	1	02	01	H5253_037_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	037	0	1	02	01	H5253_037_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	037	0	1	02	01	H5253_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	037	0	1	02	01	H5253_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				509.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	038	0	1	02	01	H5253_038_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	038	0	1	02	01	H5253_038_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	038	0	1	02	01	H5253_038_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	038	0	1	02	01	H5253_038_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	038	0	1	02	01	H5253_038_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	038	0	1	02	01	H5253_038_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	038	0	1	02	01	H5253_038_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				542.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	039	0	1	02	01	H5253_039_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	039	0	1	02	01	H5253_039_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	039	0	1	02	01	H5253_039_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	039	0	1	02	01	H5253_039_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	039	0	1	02	01	H5253_039_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	039	0	1	02	01	H5253_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	039	0	1	02	01	H5253_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				580.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	043	0	1	02	01	H5253_043_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	043	0	1	02	01	H5253_043_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	043	0	1	02	01	H5253_043_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	043	0	1	02	01	H5253_043_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	043	0	1	02	01	H5253_043_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	043	0	1	02	01	H5253_043_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				458.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	047	0	1	02	01	H5253_047_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	047	0	1	02	01	H5253_047_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	047	0	1	02	01	H5253_047_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	047	0	1	02	01	H5253_047_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	047	0	1	02	01	H5253_047_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	047	0	1	02	01	H5253_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	047	0	1	02	01	H5253_047_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				502.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	048	0	1	02	01	H5253_048_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	048	0	1	02	01	H5253_048_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	048	0	1	02	01	H5253_048_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	048	0	1	02	01	H5253_048_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	048	0	1	02	01	H5253_048_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	048	0	1	02	01	H5253_048_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	048	0	1	02	01	H5253_048_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				431.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	051	0	1	02	01	H5253_051_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	051	0	1	02	01	H5253_051_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	051	0	1	02	01	H5253_051_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	051	0	1	02	01	H5253_051_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	051	0	1	02	01	H5253_051_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	051	0	1	02	01	H5253_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	051	0	1	02	01	H5253_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	062	0	1	02	01	H5253_062_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	062	0	1	02	01	H5253_062_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	062	0	1	02	01	H5253_062_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	062	0	1	02	01	H5253_062_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	062	0	1	02	01	H5253_062_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	062	0	1	02	01	H5253_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	062	0	1	02	01	H5253_062_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				493.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	064	0	1	02	01	H5253_064_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.06						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	064	0	1	02	01	H5253_064_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	064	0	1	02	01	H5253_064_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	064	0	1	02	01	H5253_064_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	064	0	1	02	01	H5253_064_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	064	0	1	02	01	H5253_064_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				517.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	072	0	1	02	01	H5253_072_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	072	0	1	02	01	H5253_072_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	072	0	1	02	01	H5253_072_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	072	0	1	02	01	H5253_072_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	072	0	1	02	01	H5253_072_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	072	0	1	02	01	H5253_072_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	072	0	1	02	01	H5253_072_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				510.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	073	0	1	02	01	H5253_073_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	073	0	1	02	01	H5253_073_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	073	0	1	02	01	H5253_073_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	073	0	1	02	01	H5253_073_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	073	0	1	02	01	H5253_073_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	073	0	1	02	01	H5253_073_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	073	0	1	02	01	H5253_073_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				525.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	079	0	1	02	01	H5253_079_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	079	0	1	02	01	H5253_079_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	079	0	1	02	01	H5253_079_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	079	0	1	02	01	H5253_079_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	079	0	1	02	01	H5253_079_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	079	0	1	02	01	H5253_079_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	079	0	1	02	01	H5253_079_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				678.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	080	0	1	02	01	H5253_080_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	080	0	1	02	01	H5253_080_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	080	0	1	02	01	H5253_080_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	080	0	1	02	01	H5253_080_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	080	0	1	02	01	H5253_080_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	080	0	1	02	01	H5253_080_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	080	0	1	02	01	H5253_080_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				563.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	081	0	1	02	01	H5253_081_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	081	0	1	02	01	H5253_081_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	081	0	1	02	01	H5253_081_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	081	0	1	02	01	H5253_081_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	081	0	1	02	01	H5253_081_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	081	0	1	02	01	H5253_081_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	081	0	1	02	01	H5253_081_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				576.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	082	0	1	02	01	H5253_082_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	082	0	1	02	01	H5253_082_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	082	0	1	02	01	H5253_082_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	082	0	1	02	01	H5253_082_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	082	0	1	02	01	H5253_082_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	082	0	1	02	01	H5253_082_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	082	0	1	02	01	H5253_082_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				556.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	083	0	1	02	01	H5253_083_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	083	0	1	02	01	H5253_083_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	083	0	1	02	01	H5253_083_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	083	0	1	02	01	H5253_083_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	083	0	1	02	01	H5253_083_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	083	0	1	02	01	H5253_083_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	083	0	1	02	01	H5253_083_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				645.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	084	0	1	02	01	H5253_084_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	084	0	1	02	01	H5253_084_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	084	0	1	02	01	H5253_084_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	084	0	1	02	01	H5253_084_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	084	0	1	02	01	H5253_084_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	084	0	1	02	01	H5253_084_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	084	0	1	02	01	H5253_084_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				537.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	087	0	1	02	01	H5253_087_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	087	0	1	02	01	H5253_087_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	087	0	1	02	01	H5253_087_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	087	0	1	02	01	H5253_087_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	087	0	1	02	01	H5253_087_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	087	0	1	02	01	H5253_087_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	087	0	1	02	01	H5253_087_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				565.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	088	0	1	02	01	H5253_088_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	088	0	1	02	01	H5253_088_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	088	0	1	02	01	H5253_088_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	088	0	1	02	01	H5253_088_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	088	0	1	02	01	H5253_088_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	088	0	1	02	01	H5253_088_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	088	0	1	02	01	H5253_088_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				633.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	089	0	1	02	01	H5253_089_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	089	0	1	02	01	H5253_089_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	089	0	1	02	01	H5253_089_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	089	0	1	02	01	H5253_089_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	089	0	1	02	01	H5253_089_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	089	0	1	02	01	H5253_089_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	089	0	1	02	01	H5253_089_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				626.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	097	0	1	02	01	H5253_097_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	097	0	1	02	01	H5253_097_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	097	0	1	02	01	H5253_097_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	097	0	1	02	01	H5253_097_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	097	0	1	02	01	H5253_097_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	097	0	1	02	01	H5253_097_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	097	0	1	02	01	H5253_097_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	099	0	1	02	01	H5253_099_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	099	0	1	02	01	H5253_099_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	099	0	1	02	01	H5253_099_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	099	0	1	02	01	H5253_099_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	099	0	1	02	01	H5253_099_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	099	0	1	02	01	H5253_099_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	099	0	1	02	01	H5253_099_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	100	0	1	02	01	H5253_100_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	100	0	1	02	01	H5253_100_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	100	0	1	02	01	H5253_100_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	100	0	1	02	01	H5253_100_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	100	0	1	02	01	H5253_100_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	100	0	1	02	01	H5253_100_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	100	0	1	02	01	H5253_100_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				678.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	102	0	1	02	01	H5253_102_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	102	0	1	02	01	H5253_102_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	102	0	1	02	01	H5253_102_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	102	0	1	02	01	H5253_102_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	102	0	1	02	01	H5253_102_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	102	0	1	02	01	H5253_102_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	102	0	1	02	01	H5253_102_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				444.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	103	0	1	02	01	H5253_103_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	103	0	1	02	01	H5253_103_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	103	0	1	02	01	H5253_103_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	103	0	1	02	01	H5253_103_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	103	0	1	02	01	H5253_103_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	103	0	1	02	01	H5253_103_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	103	0	1	02	01	H5253_103_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				776.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	104	0	1	02	01	H5253_104_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	104	0	1	02	01	H5253_104_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	104	0	1	02	01	H5253_104_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	104	0	1	02	01	H5253_104_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	104	0	1	02	01	H5253_104_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	104	0	1	02	01	H5253_104_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	104	0	1	02	01	H5253_104_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				528.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	105	0	1	02	01	H5253_105_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	105	0	1	02	01	H5253_105_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	105	0	1	02	01	H5253_105_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	105	0	1	02	01	H5253_105_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	105	0	1	02	01	H5253_105_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	105	0	1	02	01	H5253_105_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	105	0	1	02	01	H5253_105_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				266.00	26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	107	1	1	02	01	H5253_107_1	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	107	1	1	02	01	H5253_107_1	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	107	1	1	02	01	H5253_107_1	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	107	1	1	02	01	H5253_107_1	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	107	1	1	02	01	H5253_107_1	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	107	1	1	02	01	H5253_107_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	107	1	1	02	01	H5253_107_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				481.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	107	2	1	02	01	H5253_107_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	107	2	1	02	01	H5253_107_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	107	2	1	02	01	H5253_107_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	107	2	1	02	01	H5253_107_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	107	2	1	02	01	H5253_107_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	107	2	1	02	01	H5253_107_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	107	2	1	02	01	H5253_107_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				481.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	1	1	02	01	H5253_108_1	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	1	1	02	01	H5253_108_1	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	108	1	1	02	01	H5253_108_1	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	1	1	02	01	H5253_108_1	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	108	1	1	02	01	H5253_108_1	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	108	1	1	02	01	H5253_108_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	108	1	1	02	01	H5253_108_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	2	1	02	01	H5253_108_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	2	1	02	01	H5253_108_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	108	2	1	02	01	H5253_108_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	2	1	02	01	H5253_108_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	108	2	1	02	01	H5253_108_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	108	2	1	02	01	H5253_108_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	108	2	1	02	01	H5253_108_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	3	1	02	01	H5253_108_3	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	3	1	02	01	H5253_108_3	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	108	3	1	02	01	H5253_108_3	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	108	3	1	02	01	H5253_108_3	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	108	3	1	02	01	H5253_108_3	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	108	3	1	02	01	H5253_108_3	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	108	3	1	02	01	H5253_108_3	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	1	1	02	01	H5253_109_1	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	1	1	02	01	H5253_109_1	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	109	1	1	02	01	H5253_109_1	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	1	1	02	01	H5253_109_1	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	109	1	1	02	01	H5253_109_1	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	109	1	1	02	01	H5253_109_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	109	1	1	02	01	H5253_109_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				510.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	2	1	02	01	H5253_109_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	2	1	02	01	H5253_109_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	109	2	1	02	01	H5253_109_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	2	1	02	01	H5253_109_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	109	2	1	02	01	H5253_109_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	109	2	1	02	01	H5253_109_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	109	2	1	02	01	H5253_109_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				510.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	4	1	02	01	H5253_109_4	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	4	1	02	01	H5253_109_4	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	109	4	1	02	01	H5253_109_4	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	109	4	1	02	01	H5253_109_4	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	109	4	1	02	01	H5253_109_4	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	109	4	1	02	01	H5253_109_4	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	109	4	1	02	01	H5253_109_4	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				510.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	110	0	1	02	01	H5253_110_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	110	0	1	02	01	H5253_110_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	110	0	1	02	01	H5253_110_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	110	0	1	02	01	H5253_110_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	110	0	1	02	01	H5253_110_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	110	0	1	02	01	H5253_110_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	110	0	1	02	01	H5253_110_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				264.00	26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	111	1	1	02	01	H5253_111_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	111	1	1	02	01	H5253_111_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	111	1	1	02	01	H5253_111_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	111	1	1	02	01	H5253_111_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	111	1	1	02	01	H5253_111_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	111	1	1	02	01	H5253_111_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	111	1	1	02	01	H5253_111_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	111	2	1	02	01	H5253_111_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	111	2	1	02	01	H5253_111_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	111	2	1	02	01	H5253_111_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	111	2	1	02	01	H5253_111_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	111	2	1	02	01	H5253_111_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	111	2	1	02	01	H5253_111_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	111	2	1	02	01	H5253_111_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	112	1	1	02	01	H5253_112_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	112	1	1	02	01	H5253_112_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	112	1	1	02	01	H5253_112_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	112	1	1	02	01	H5253_112_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	112	1	1	02	01	H5253_112_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	112	1	1	02	01	H5253_112_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	112	1	1	02	01	H5253_112_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				600.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	112	2	1	02	01	H5253_112_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	112	2	1	02	01	H5253_112_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	112	2	1	02	01	H5253_112_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	112	2	1	02	01	H5253_112_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	112	2	1	02	01	H5253_112_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	112	2	1	02	01	H5253_112_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	112	2	1	02	01	H5253_112_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				600.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	117	0	1	02	01	H5253_117_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	117	0	1	02	01	H5253_117_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	117	0	1	02	01	H5253_117_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	117	0	1	02	01	H5253_117_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	117	0	1	02	01	H5253_117_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	117	0	1	02	01	H5253_117_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	117	0	1	02	01	H5253_117_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				459.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	119	0	1	02	01	H5253_119_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	119	0	1	02	01	H5253_119_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	119	0	1	02	01	H5253_119_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	119	0	1	02	01	H5253_119_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	119	0	1	02	01	H5253_119_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	119	0	1	02	01	H5253_119_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	119	0	1	02	01	H5253_119_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				299.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	120	0	1	02	01	H5253_120_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	120	0	1	02	01	H5253_120_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	120	0	1	02	01	H5253_120_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	120	0	1	02	01	H5253_120_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	120	0	1	02	01	H5253_120_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	120	0	1	02	01	H5253_120_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	120	0	1	02	01	H5253_120_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				612.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	121	0	1	02	01	H5253_121_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	121	0	1	02	01	H5253_121_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	121	0	1	02	01	H5253_121_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	121	0	1	02	01	H5253_121_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	121	0	1	02	01	H5253_121_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	121	0	1	02	01	H5253_121_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	121	0	1	02	01	H5253_121_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				341.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	124	1	1	02	01	H5253_124_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	124	1	1	02	01	H5253_124_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	124	1	1	02	01	H5253_124_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	124	1	1	02	01	H5253_124_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	124	1	1	02	01	H5253_124_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	124	1	1	02	01	H5253_124_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	124	1	1	02	01	H5253_124_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				460.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	124	2	1	02	01	H5253_124_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	124	2	1	02	01	H5253_124_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	124	2	1	02	01	H5253_124_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	124	2	1	02	01	H5253_124_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5253	124	2	1	02	01	H5253_124_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	124	2	1	02	01	H5253_124_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	124	2	1	02	01	H5253_124_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				460.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	125	1	1	02	01	H5253_125_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	125	1	1	02	01	H5253_125_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	125	1	1	02	01	H5253_125_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	125	1	1	02	01	H5253_125_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	125	1	1	02	01	H5253_125_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	125	1	1	02	01	H5253_125_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	125	1	1	02	01	H5253_125_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				497.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	125	2	1	02	01	H5253_125_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	125	2	1	02	01	H5253_125_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	125	2	1	02	01	H5253_125_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	125	2	1	02	01	H5253_125_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	125	2	1	02	01	H5253_125_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	125	2	1	02	01	H5253_125_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	125	2	1	02	01	H5253_125_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				497.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	126	1	1	02	01	H5253_126_1	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	126	1	1	02	01	H5253_126_1	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	126	1	1	02	01	H5253_126_1	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	126	1	1	02	01	H5253_126_1	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	126	1	1	02	01	H5253_126_1	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	126	1	1	02	01	H5253_126_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	126	1	1	02	01	H5253_126_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				347.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	126	2	1	02	01	H5253_126_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	126	2	1	02	01	H5253_126_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	126	2	1	02	01	H5253_126_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	126	2	1	02	01	H5253_126_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	126	2	1	02	01	H5253_126_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	126	2	1	02	01	H5253_126_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	126	2	1	02	01	H5253_126_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				347.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	127	0	1	02	01	H5253_127_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	127	0	1	02	01	H5253_127_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	127	0	1	02	01	H5253_127_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	127	0	1	02	01	H5253_127_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	127	0	1	02	01	H5253_127_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	127	0	1	02	01	H5253_127_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	127	0	1	02	01	H5253_127_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				270.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	128	0	1	02	01	H5253_128_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	128	0	1	02	01	H5253_128_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	128	0	1	02	01	H5253_128_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	128	0	1	02	01	H5253_128_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	128	0	1	02	01	H5253_128_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	128	0	1	02	01	H5253_128_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	128	0	1	02	01	H5253_128_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				498.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	130	0	1	02	01	H5253_130_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	130	0	1	02	01	H5253_130_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	130	0	1	02	01	H5253_130_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	130	0	1	02	01	H5253_130_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	130	0	1	02	01	H5253_130_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	130	0	1	02	01	H5253_130_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	130	0	1	02	01	H5253_130_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	131	0	1	02	01	H5253_131_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	131	0	1	02	01	H5253_131_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	131	0	1	02	01	H5253_131_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	131	0	1	02	01	H5253_131_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	131	0	1	02	01	H5253_131_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	131	0	1	02	01	H5253_131_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	131	0	1	02	01	H5253_131_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	132	0	1	02	01	H5253_132_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	132	0	1	02	01	H5253_132_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	132	0	1	02	01	H5253_132_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	132	0	1	02	01	H5253_132_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	132	0	1	02	01	H5253_132_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	132	0	1	02	01	H5253_132_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	132	0	1	02	01	H5253_132_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				264.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	133	0	1	02	01	H5253_133_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	133	0	1	02	01	H5253_133_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	133	0	1	02	01	H5253_133_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	133	0	1	02	01	H5253_133_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	133	0	1	02	01	H5253_133_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	133	0	1	02	01	H5253_133_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	133	0	1	02	01	H5253_133_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				520.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	134	0	1	02	01	H5253_134_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	134	0	1	02	01	H5253_134_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	134	0	1	02	01	H5253_134_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	134	0	1	02	01	H5253_134_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	134	0	1	02	01	H5253_134_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	134	0	1	02	01	H5253_134_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	134	0	1	02	01	H5253_134_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				498.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	135	0	1	02	01	H5253_135_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	135	0	1	02	01	H5253_135_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	135	0	1	02	01	H5253_135_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	135	0	1	02	01	H5253_135_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	135	0	1	02	01	H5253_135_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	135	0	1	02	01	H5253_135_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	135	0	1	02	01	H5253_135_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				266.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	136	0	1	02	01	H5253_136_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	136	0	1	02	01	H5253_136_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	136	0	1	02	01	H5253_136_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	136	0	1	02	01	H5253_136_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	136	0	1	02	01	H5253_136_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H5253	136	0	1	02	01	H5253_136_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	136	0	1	02	01	H5253_136_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				436.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	141	0	1	02	01	H5253_141_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	141	0	1	02	01	H5253_141_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	141	0	1	02	01	H5253_141_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	141	0	1	02	01	H5253_141_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	141	0	1	02	01	H5253_141_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	141	0	1	02	01	H5253_141_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	141	0	1	02	01	H5253_141_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				510.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	142	0	1	02	01	H5253_142_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	142	0	1	02	01	H5253_142_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	142	0	1	02	01	H5253_142_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	142	0	1	02	01	H5253_142_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	142	0	1	02	01	H5253_142_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	142	0	1	02	01	H5253_142_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	142	0	1	02	01	H5253_142_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				665.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	144	1	1	02	01	H5253_144_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	144	1	1	02	01	H5253_144_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	144	1	1	02	01	H5253_144_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	144	1	1	02	01	H5253_144_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	144	1	1	02	01	H5253_144_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	144	1	1	02	01	H5253_144_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	144	1	1	02	01	H5253_144_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	144	2	1	02	01	H5253_144_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	144	2	1	02	01	H5253_144_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5253	144	2	1	02	01	H5253_144_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5253	144	2	1	02	01	H5253_144_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5253	144	2	1	02	01	H5253_144_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	144	2	1	02	01	H5253_144_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5253	144	2	1	02	01	H5253_144_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				484.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5262	001	0	1	01	01	H5262_001_0	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	001	0	1	01	01	H5262_001_0	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	001	0	1	01	01	H5262_001_0	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	001	0	1	01	01	H5262_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	001	0	1	01	01	H5262_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	001	0	1	01	01	H5262_001_0	5			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	001	0	1	01	01	H5262_001_0	5			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	003	0	1	01	01	H5262_003_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	003	0	1	01	01	H5262_003_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	003	0	1	01	01	H5262_003_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	003	0	1	01	01	H5262_003_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	003	0	1	01	01	H5262_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	003	0	1	01	01	H5262_003_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	003	0	1	01	01	H5262_003_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	007	0	1	01	01	H5262_007_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	007	0	1	01	01	H5262_007_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	007	0	1	01	01	H5262_007_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	007	0	1	01	01	H5262_007_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	007	0	1	01	01	H5262_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	007	0	1	01	01	H5262_007_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	007	0	1	01	01	H5262_007_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	008	0	1	01	01	H5262_008_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	008	0	1	01	01	H5262_008_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	008	0	1	01	01	H5262_008_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	008	0	1	01	01	H5262_008_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	008	0	1	01	01	H5262_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	008	0	1	01	01	H5262_008_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	008	0	1	01	01	H5262_008_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	011	0	1	01	01	H5262_011_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	011	0	1	01	01	H5262_011_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					0.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	011	0	1	01	01	H5262_011_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					118.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	011	0	1	01	01	H5262_011_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	011	0	1	01	01	H5262_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	011	0	1	01	01	H5262_011_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	011	0	1	01	01	H5262_011_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	012	0	1	01	01	H5262_012_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	012	0	1	01	01	H5262_012_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					0.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	012	0	1	01	01	H5262_012_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					118.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	012	0	1	01	01	H5262_012_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	012	0	1	01	01	H5262_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	012	0	1	01	01	H5262_012_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	012	0	1	01	01	H5262_012_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	018	0	1	01	01	H5262_018_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	018	0	1	01	01	H5262_018_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	20.00	40.00	60.00																					50.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	018	0	1	01	01	H5262_018_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	018	0	1	01	01	H5262_018_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	018	0	1	01	01	H5262_018_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	018	0	1	01	01	H5262_018_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	018	0	1	01	01	H5262_018_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	019	0	1	01	01	H5262_019_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	019	0	1	01	01	H5262_019_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	20.00	40.00	60.00																					50.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	019	0	1	01	01	H5262_019_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	019	0	1	01	01	H5262_019_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	019	0	1	01	01	H5262_019_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	019	0	1	01	01	H5262_019_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	019	0	1	01	01	H5262_019_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	021	0	1	01	01	H5262_021_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	021	0	1	01	01	H5262_021_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	021	0	1	01	01	H5262_021_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	021	0	1	01	01	H5262_021_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	021	0	1	01	01	H5262_021_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	021	0	1	01	01	H5262_021_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	021	0	1	01	01	H5262_021_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	023	0	1	01	01	H5262_023_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	023	0	1	01	01	H5262_023_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	023	0	1	01	01	H5262_023_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	023	0	1	01	01	H5262_023_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	023	0	1	01	01	H5262_023_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	023	0	1	01	01	H5262_023_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	023	0	1	01	01	H5262_023_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	024	0	1	01	01	H5262_024_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	024	0	1	01	01	H5262_024_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					0.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	024	0	1	01	01	H5262_024_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					118.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	024	0	1	01	01	H5262_024_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	024	0	1	01	01	H5262_024_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	024	0	1	01	01	H5262_024_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	024	0	1	01	01	H5262_024_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	026	0	1	01	01	H5262_026_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	30.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	026	0	1	01	01	H5262_026_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	20.00	40.00	60.00																					50.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	026	0	1	01	01	H5262_026_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	026	0	1	01	01	H5262_026_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	026	0	1	01	01	H5262_026_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	026	0	1	01	01	H5262_026_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	026	0	1	01	01	H5262_026_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5262	029	0	1	01	01	H5262_029_0	4		N	Preferred Generic	2	01	1	1	1	1	111		01	100		1	30	60	90				1	2			90				30		31				1.86	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	029	0	1	01	01	H5262_029_0	4		N	Generic	2	01	1	1	2	1	111		01	100		1	30	60	90				1	1			90				30		31				6.83	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	029	0	1	01	01	H5262_029_0	4		N	Preferred Brand	2	10	1	1	3	1	111		01	100		1	30	60	90				1	1			90				30		31				118.34	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	029	0	1	01	01	H5262_029_0	4		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	100		1	30	60	90				1	1			90				30		31				91.64	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	029	0	1	01	01	H5262_029_0	4		N	Specialty Tier	2	11	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	029	0	1	01	01	H5262_029_0	4		N	Vaccines ($0 cost sharing)	2	11	1	1	6	1	010		01	000		1	30														30		31				0.00	0																																					0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	030	0	1	01	01	H5262_030_0	4		N	Preferred Generic	2	01	1	1	1	1	111		01	100		1	30	60	90				1	2			90				30		31				1.86	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	030	0	1	01	01	H5262_030_0	4		N	Generic	2	01	1	1	2	1	111		01	100		1	30	60	90				1	1			90				30		31				6.83	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	030	0	1	01	01	H5262_030_0	4		N	Preferred Brand	2	10	1	1	3	1	111		01	100		1	30	60	90				1	1			90				30		31				118.34	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	030	0	1	01	01	H5262_030_0	4		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	100		1	30	60	90				1	1			90				30		31				91.64	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	030	0	1	01	01	H5262_030_0	4		N	Specialty Tier	2	11	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	030	0	1	01	01	H5262_030_0	4		N	Vaccines ($0 cost sharing)	2	11	1	1	6	1	010		01	000		1	30														30		31				0.00	0																																					0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	031	0	1	01	01	H5262_031_0	4		N	Preferred Generic	2	01	1	1	1	1	111		01	100		1	30	60	90				1	2			90				30		31				1.86	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	031	0	1	01	01	H5262_031_0	4		N	Generic	2	01	1	1	2	1	111		01	100		1	30	60	90				1	1			90				30		31				6.83	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	031	0	1	01	01	H5262_031_0	4		N	Preferred Brand	2	10	1	1	3	1	111		01	100		1	30	60	90				1	1			90				30		31				118.34	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H5262	031	0	1	01	01	H5262_031_0	4		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	100		1	30	60	90				1	1			90				30		31				91.64	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	031	0	1	01	01	H5262_031_0	4		N	Specialty Tier	2	11	1	1	5	1	010		01	000		1	30														30		31					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5262	031	0	1	01	01	H5262_031_0	4		N	Vaccines ($0 cost sharing)	2	11	1	1	6	1	010		01	000		1	30														30		31				0.00	0																																					0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5273	001	0	1	01	01	H5273_001_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		0.00
H5273	001	0	1	01	01	H5273_001_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					0.00	0.00	0.00																15.00				0.00			0.50	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		0.00
H5273	001	0	1	01	01	H5273_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5273	001	0	1	01	01	H5273_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5273	001	0	1	01	01	H5273_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5273	001	0	1	01	01	H5273_001_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H5273	001	0	1	01	01	H5273_001_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H5280	001	0	1	48	05	H5280_001_0	6			Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H5280	001	0	1	48	05	H5280_001_0	6			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H5280	001	0	1	48	05	H5280_001_0	6			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31								31						31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H5294	011	0	1	01	01	H5294_011_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	011	0	1	01	01	H5294_011_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5294	011	0	1	01	01	H5294_011_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	0.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	011	0	1	01	01	H5294_011_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5294	011	0	1	01	01	H5294_011_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.37	37	37	37				97.37	37	37	37										37	37	37				37	37	37			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	011	0	1	01	01	H5294_011_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	011	0	1	01	01	H5294_011_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	011	0	1	01	01	H5294_011_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5294	012	0	1	01	01	H5294_012_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	012	0	1	01	01	H5294_012_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	0.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	012	0	1	01	01	H5294_012_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5294	012	0	1	01	01	H5294_012_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.74	36	36	36				98.74	36	36	36										36	36	36				36	36	36			36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	012	0	1	01	01	H5294_012_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	012	0	1	01	01	H5294_012_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	013	0	1	01	01	H5294_013_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	013	0	1	01	01	H5294_013_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	013	0	1	01	01	H5294_013_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H5294	013	0	1	01	01	H5294_013_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.46	43	43	43				98.46	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	013	0	1	01	01	H5294_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	013	0	1	01	01	H5294_013_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	016	0	1	01	01	H5294_016_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	016	0	1	01	01	H5294_016_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	016	0	1	01	01	H5294_016_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H5294	016	0	1	01	01	H5294_016_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.17	50	50	50				97.17	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	016	0	1	01	01	H5294_016_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	016	0	1	01	01	H5294_016_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	017	0	1	01	01	H5294_017_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	017	0	1	01	01	H5294_017_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5294	017	0	1	01	01	H5294_017_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	0.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	017	0	1	01	01	H5294_017_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5294	017	0	1	01	01	H5294_017_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.21	49	49	49				98.21	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	017	0	1	01	01	H5294_017_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	017	0	1	01	01	H5294_017_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	017	0	1	01	01	H5294_017_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5294	018	0	1	01	01	H5294_018_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	018	0	1	01	01	H5294_018_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5294	018	0	1	01	01	H5294_018_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					14.00	28.00	42.00											19.00	38.00	57.00				14.00	28.00	0.00				19.00				19.00			0.63	0.47		0.63	0.47	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	018	0	1	01	01	H5294_018_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5294	018	0	1	01	01	H5294_018_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.83	50	50	50				91.83	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	018	0	1	01	01	H5294_018_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	018	0	1	01	01	H5294_018_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	018	0	1	01	01	H5294_018_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5294	019	0	1	01	01	H5294_019_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	019	0	1	01	01	H5294_019_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	019	0	1	01	01	H5294_019_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5294	019	0	1	01	01	H5294_019_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.70	49	49	49				99.70	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	019	0	1	01	01	H5294_019_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	019	0	1	01	01	H5294_019_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	020	0	1	01	01	H5294_020_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	020	0	1	01	01	H5294_020_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5294	020	0	1	01	01	H5294_020_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.00	34.00	51.00					12.00	24.00	36.00											17.00	34.00	51.00				12.00	24.00	0.00				17.00				17.00			0.57	0.40		0.57	0.40	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	020	0	1	01	01	H5294_020_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5294	020	0	1	01	01	H5294_020_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.45	50	50	50				88.45	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5294	020	0	1	01	01	H5294_020_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5294	020	0	1	01	01	H5294_020_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5294	020	0	1	01	01	H5294_020_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5296	003	0	1	02	01	H5296_003_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	003	0	1	02	01	H5296_003_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	003	0	1	02	01	H5296_003_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	003	0	1	02	01	H5296_003_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	003	0	1	02	01	H5296_003_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	003	0	1	02	01	H5296_003_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				502.07	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	003	0	1	02	01	H5296_003_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	003	0	1	02	01	H5296_003_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	005	0	1	02	01	H5296_005_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	005	0	1	02	01	H5296_005_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	005	0	1	02	01	H5296_005_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	005	0	1	02	01	H5296_005_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	75.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													30.00	60.00	90.00				30.00	60.00	75.00				30.00		30.00
H5296	005	0	1	02	01	H5296_005_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	75.00	150.00	225.00																			75.00	150.00	187.50																75.00				75.00		2.50			2.50			2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	005	0	1	02	01	H5296_005_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				758.79	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	005	0	1	02	01	H5296_005_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	005	0	1	02	01	H5296_005_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	006	0	1	01	01	H5296_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	006	0	1	01	01	H5296_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	006	0	1	01	01	H5296_006_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	006	0	1	01	01	H5296_006_0	10			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	006	0	1	01	01	H5296_006_0	10			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	006	0	1	01	01	H5296_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				511.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	006	0	1	01	01	H5296_006_0	10			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	006	0	1	01	01	H5296_006_0	10			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	007	0	1	01	01	H5296_007_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	007	0	1	01	01	H5296_007_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	007	0	1	01	01	H5296_007_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	007	0	1	01	01	H5296_007_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	007	0	1	01	01	H5296_007_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	007	0	1	01	01	H5296_007_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				611.33	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	007	0	1	01	01	H5296_007_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	007	0	1	01	01	H5296_007_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	008	0	1	01	01	H5296_008_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	008	0	1	01	01	H5296_008_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5296	008	0	1	01	01	H5296_008_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5296	008	0	1	01	01	H5296_008_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	008	0	1	01	01	H5296_008_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5296	008	0	1	01	01	H5296_008_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				511.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	008	0	1	01	01	H5296_008_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5296	008	0	1	01	01	H5296_008_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5299	001	0	1	01	01	H5299_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	001	0	1	01	01	H5299_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H5299	001	0	1	01	01	H5299_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	001	0	1	01	01	H5299_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H5299	001	0	1	01	01	H5299_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	001	0	1	01	01	H5299_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	001	0	1	01	01	H5299_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H5299	002	0	1	01	01	H5299_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	002	0	1	01	01	H5299_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H5299	002	0	1	01	01	H5299_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	002	0	1	01	01	H5299_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H5299	002	0	1	01	01	H5299_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	002	0	1	01	01	H5299_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	002	0	1	01	01	H5299_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H5299	003	0	1	01	01	H5299_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	003	0	1	01	01	H5299_003_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H5299	003	0	1	01	01	H5299_003_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	003	0	1	01	01	H5299_003_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H5299	003	0	1	01	01	H5299_003_0	11			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	003	0	1	01	01	H5299_003_0	11			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	003	0	1	01	01	H5299_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H5299	004	0	1	01	01	H5299_004_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	004	0	1	01	01	H5299_004_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H5299	004	0	1	01	01	H5299_004_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H5299	004	0	1	01	01	H5299_004_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H5299	004	0	1	01	01	H5299_004_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5299	004	0	1	01	01	H5299_004_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5299	004	0	1	01	01	H5299_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H5299	012	0	1	01	01	H5299_012_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5299	012	0	1	01	01	H5299_012_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H5299	012	0	1	01	01	H5299_012_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H5299	012	0	1	01	01	H5299_012_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H5299	012	0	1	01	01	H5299_012_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	012	0	1	01	01	H5299_012_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H5299	012	0	1	01	01	H5299_012_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H5302	019	0	1	01	01	H5302_019_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5302	019	0	1	01	01	H5302_019_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5302	019	0	1	01	01	H5302_019_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5302	019	0	1	01	01	H5302_019_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5302	019	0	1	01	01	H5302_019_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5302	019	0	1	01	01	H5302_019_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5302	019	0	1	01	01	H5302_019_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											900.26	33						691.40	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5309	001	0	1	04	01	H5309_001_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	001	0	1	04	01	H5309_001_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5309	001	0	1	04	01	H5309_001_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	001	0	1	04	01	H5309_001_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5309	001	0	1	04	01	H5309_001_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5309	001	0	1	04	01	H5309_001_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	001	0	1	04	01	H5309_001_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5309	002	0	1	04	01	H5309_002_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	002	0	1	04	01	H5309_002_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5309	002	0	1	04	01	H5309_002_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	002	0	1	04	01	H5309_002_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5309	002	0	1	04	01	H5309_002_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5309	002	0	1	04	01	H5309_002_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	002	0	1	04	01	H5309_002_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5309	003	0	1	04	01	H5309_003_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	003	0	1	04	01	H5309_003_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5309	003	0	1	04	01	H5309_003_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	003	0	1	04	01	H5309_003_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5309	003	0	1	04	01	H5309_003_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5309	003	0	1	04	01	H5309_003_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5309	003	0	1	04	01	H5309_003_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5322	026	0	1	02	01	H5322_026_0	6		N	Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				1.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	026	0	1	02	01	H5322_026_0	6		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				3.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	026	0	1	02	01	H5322_026_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				67.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5322	026	0	1	02	01	H5322_026_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		100				2	2			100				30		31				43.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5322	026	0	1	02	01	H5322_026_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				370.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	039	0	1	02	01	H5322_039_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	039	0	1	02	01	H5322_039_0	5			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5322	039	0	1	02	01	H5322_039_0	5			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	039	0	1	02	01	H5322_039_0	5			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5322	039	0	1	02	01	H5322_039_0	5			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H5322	039	0	1	02	01	H5322_039_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								95.00		285.00					95.00		275.00													285.00						275.00				95.00				95.00			3.16	3.16				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H5322	039	0	1	02	01	H5322_039_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											637.00	33						774.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	040	0	1	02	01	H5322_040_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	040	0	1	02	01	H5322_040_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5322	040	0	1	02	01	H5322_040_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	040	0	1	02	01	H5322_040_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5322	040	0	1	02	01	H5322_040_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	040	0	1	02	01	H5322_040_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	040	0	1	02	01	H5322_040_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				591.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	041	0	1	02	01	H5322_041_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	041	0	1	02	01	H5322_041_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5322	041	0	1	02	01	H5322_041_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	041	0	1	02	01	H5322_041_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5322	041	0	1	02	01	H5322_041_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	041	0	1	02	01	H5322_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	041	0	1	02	01	H5322_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				613.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	042	0	1	02	01	H5322_042_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	042	0	1	02	01	H5322_042_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5322	042	0	1	02	01	H5322_042_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	042	0	1	02	01	H5322_042_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5322	042	0	1	02	01	H5322_042_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	042	0	1	02	01	H5322_042_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	042	0	1	02	01	H5322_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				542.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	044	0	1	02	01	H5322_044_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	044	0	1	02	01	H5322_044_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5322	044	0	1	02	01	H5322_044_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5322	044	0	1	02	01	H5322_044_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5322	044	0	1	02	01	H5322_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	044	0	1	02	01	H5322_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5322	044	0	1	02	01	H5322_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				616.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	001	0	1	04	01	H5361_001_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	001	0	1	04	01	H5361_001_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	001	0	1	04	01	H5361_001_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	001	0	1	04	01	H5361_001_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	001	0	1	04	01	H5361_001_0	4			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	002	0	1	04	01	H5361_002_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	002	0	1	04	01	H5361_002_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	002	0	1	04	01	H5361_002_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	002	0	1	04	01	H5361_002_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	002	0	1	04	01	H5361_002_0	4			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												28	28	28					28	28	28				28	28	28															28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	003	0	1	04	01	H5361_003_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	003	0	1	04	01	H5361_003_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	003	0	1	04	01	H5361_003_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	003	0	1	04	01	H5361_003_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	003	0	1	04	01	H5361_003_0	4			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												30	30	30					30	30	30				30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	004	0	1	04	01	H5361_004_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	27.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	004	0	1	04	01	H5361_004_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5361	004	0	1	04	01	H5361_004_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	004	0	1	04	01	H5361_004_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5361	004	0	1	04	01	H5361_004_0	4			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												25	25	25					25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5373	001	0	1	02	01	H5373_001_0	10			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5373	001	0	1	02	01	H5373_001_0	10			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5373	001	0	1	02	01	H5373_001_0	10			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5373	001	0	1	02	01	H5373_001_0	10			Generic	4	11	1	2	2	3	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5373	001	0	1	02	01	H5373_001_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5373	001	0	1	02	01	H5373_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5373	001	0	1	02	01	H5373_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1091.41	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H5377	002	0	1	02	01	H5377_002_0	11			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5377	002	0	1	02	01	H5377_002_0	11			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5377	002	0	1	02	01	H5377_002_0	11			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5377	002	0	1	02	01	H5377_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5377	002	0	1	02	01	H5377_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5386	003	0	1	01	01	H5386_003_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	2.00	4.00	6.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	003	0	1	01	01	H5386_003_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	003	0	1	01	01	H5386_003_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5386	003	0	1	01	01	H5386_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5386	003	0	1	01	01	H5386_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				763.51	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5386	003	0	1	01	01	H5386_003_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	004	0	1	01	01	H5386_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	2.00	4.00	6.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	004	0	1	01	01	H5386_004_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	004	0	1	01	01	H5386_004_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5386	004	0	1	01	01	H5386_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5386	004	0	1	01	01	H5386_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				795.69	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5386	004	0	1	01	01	H5386_004_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	005	0	1	01	01	H5386_005_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	2.00	4.00	6.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	005	0	1	01	01	H5386_005_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5386	005	0	1	01	01	H5386_005_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5386	005	0	1	01	01	H5386_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5386	005	0	1	01	01	H5386_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				763.51	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5386	005	0	1	01	01	H5386_005_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5398	002	0	1	01	01	H5398_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5398	002	0	1	01	01	H5398_002_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5398	002	0	1	01	01	H5398_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5398	002	0	1	01	01	H5398_002_0	17			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5398	002	0	1	01	01	H5398_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H5398	002	0	1	01	01	H5398_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.92	50	50	50				84.92	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5398	002	0	1	01	01	H5398_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H5398	002	0	1	01	01	H5398_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5398	002	0	1	01	01	H5398_002_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5398	004	0	1	01	01	H5398_004_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5398	004	0	1	01	01	H5398_004_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5398	004	0	1	01	01	H5398_004_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5398	004	0	1	01	01	H5398_004_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											83.69	50	50	50				83.69	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5398	004	0	1	01	01	H5398_004_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5398	004	0	1	01	01	H5398_004_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5410	018	0	1	01	01	H5410_018_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H5410	018	0	1	01	01	H5410_018_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5410	018	0	1	01	01	H5410_018_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H5410	018	0	1	01	01	H5410_018_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	018	0	1	01	01	H5410_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	018	0	1	01	01	H5410_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											600.37	33						739.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	024	0	1	01	01	H5410_024_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	024	0	1	01	01	H5410_024_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	024	0	1	01	01	H5410_024_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	024	0	1	01	01	H5410_024_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	024	0	1	01	01	H5410_024_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					25.00	50.00	75.00											47.00	94.00	141.00				25.00	50.00	75.00				47.00				47.00			1.57	0.83		1.57	0.83	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	25.00	50.00	75.00	35.00	70.00	105.00	25.00	50.00	75.00	35.00		35.00
H5410	024	0	1	01	01	H5410_024_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	024	0	1	01	01	H5410_024_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											493.60	33						417.80	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	026	0	1	01	01	H5410_026_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	026	0	1	01	01	H5410_026_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	026	0	1	01	01	H5410_026_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	026	0	1	01	01	H5410_026_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	026	0	1	01	01	H5410_026_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					25.00	50.00	75.00											47.00	94.00	141.00				25.00	50.00	75.00				47.00				47.00			1.57	0.83		1.57	0.83	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	25.00	50.00	75.00	35.00	70.00	105.00	25.00	50.00	75.00	35.00		35.00
H5410	026	0	1	01	01	H5410_026_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	026	0	1	01	01	H5410_026_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											646.26	33						578.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	027	0	1	01	01	H5410_027_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	027	0	1	01	01	H5410_027_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5410	027	0	1	01	01	H5410_027_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	027	0	1	01	01	H5410_027_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	027	0	1	01	01	H5410_027_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	027	0	1	01	01	H5410_027_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											610.71	33						475.10	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	028	0	1	01	01	H5410_028_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H5410	028	0	1	01	01	H5410_028_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5410	028	0	1	01	01	H5410_028_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H5410	028	0	1	01	01	H5410_028_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	028	0	1	01	01	H5410_028_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	028	0	1	01	01	H5410_028_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											646.11	33						540.13	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	029	0	1	01	01	H5410_029_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H5410	029	0	1	01	01	H5410_029_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5410	029	0	1	01	01	H5410_029_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H5410	029	0	1	01	01	H5410_029_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	029	0	1	01	01	H5410_029_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	029	0	1	01	01	H5410_029_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											672.61	33						420.02	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	030	0	1	01	01	H5410_030_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H5410	030	0	1	01	01	H5410_030_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5410	030	0	1	01	01	H5410_030_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H5410	030	0	1	01	01	H5410_030_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	030	0	1	01	01	H5410_030_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	030	0	1	01	01	H5410_030_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											638.23	33						531.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	037	0	1	01	01	H5410_037_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	037	0	1	01	01	H5410_037_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	037	0	1	01	01	H5410_037_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	037	0	1	01	01	H5410_037_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	037	0	1	01	01	H5410_037_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	037	0	1	01	01	H5410_037_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	037	0	1	01	01	H5410_037_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.24	33						505.24	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	039	0	1	01	01	H5410_039_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	039	0	1	01	01	H5410_039_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	039	0	1	01	01	H5410_039_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	039	0	1	01	01	H5410_039_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	039	0	1	01	01	H5410_039_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	039	0	1	01	01	H5410_039_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	039	0	1	01	01	H5410_039_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											600.27	33						507.58	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	040	0	1	01	01	H5410_040_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	040	0	1	01	01	H5410_040_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	040	0	1	01	01	H5410_040_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	040	0	1	01	01	H5410_040_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	040	0	1	01	01	H5410_040_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	040	0	1	01	01	H5410_040_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	040	0	1	01	01	H5410_040_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											617.32	33						483.24	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	041	0	1	01	01	H5410_041_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H5410	041	0	1	01	01	H5410_041_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	041	0	1	01	01	H5410_041_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H5410	041	0	1	01	01	H5410_041_0	8			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	041	0	1	01	01	H5410_041_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	041	0	1	01	01	H5410_041_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	041	0	1	01	01	H5410_041_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											607.66	33						567.93	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	043	0	1	01	01	H5410_043_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	043	0	1	01	01	H5410_043_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	043	0	1	01	01	H5410_043_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	043	0	1	01	01	H5410_043_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	043	0	1	01	01	H5410_043_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	043	0	1	01	01	H5410_043_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	043	0	1	01	01	H5410_043_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											648.67	33						534.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	044	0	1	01	01	H5410_044_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	044	0	1	01	01	H5410_044_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	044	0	1	01	01	H5410_044_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	044	0	1	01	01	H5410_044_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	044	0	1	01	01	H5410_044_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	044	0	1	01	01	H5410_044_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	044	0	1	01	01	H5410_044_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											648.21	33						534.52	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	048	0	1	01	01	H5410_048_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H5410	048	0	1	01	01	H5410_048_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	048	0	1	01	01	H5410_048_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H5410	048	0	1	01	01	H5410_048_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	048	0	1	01	01	H5410_048_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					5.00	10.00	15.00											47.00	94.00	141.00				5.00	10.00	15.00				47.00				47.00			1.57	0.17		1.57	0.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	5.00	10.00	15.00	35.00	70.00	105.00	5.00	10.00	15.00	35.00		35.00
H5410	048	0	1	01	01	H5410_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					90.00	180.00	270.00											100.00	200.00	300.00				90.00	180.00	270.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	048	0	1	01	01	H5410_048_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											616.81	33						501.93	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	050	0	1	01	01	H5410_050_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	050	0	1	01	01	H5410_050_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	050	0	1	01	01	H5410_050_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	050	0	1	01	01	H5410_050_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	050	0	1	01	01	H5410_050_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	050	0	1	01	01	H5410_050_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	050	0	1	01	01	H5410_050_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.15	33						502.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	051	0	1	01	01	H5410_051_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5410	051	0	1	01	01	H5410_051_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	051	0	1	01	01	H5410_051_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H5410	051	0	1	01	01	H5410_051_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	051	0	1	01	01	H5410_051_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00
H5410	051	0	1	01	01	H5410_051_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								50.00	100.00	150.00					35.00	70.00	105.00											50.00	100.00	150.00				35.00	70.00	105.00				50.00				50.00			1.67	1.17		1.67	1.17	1.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	051	0	1	01	01	H5410_051_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											619.26	33						498.92	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	052	0	1	01	01	H5410_052_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H5410	052	0	1	01	01	H5410_052_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	052	0	1	01	01	H5410_052_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	052	0	1	01	01	H5410_052_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	052	0	1	01	01	H5410_052_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					10.00	20.00	30.00											47.00	94.00	141.00				10.00	20.00	30.00				47.00				47.00			1.57	0.33		1.57	0.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	10.00	20.00	30.00	35.00	70.00	105.00	10.00	20.00	30.00	35.00		35.00
H5410	052	0	1	01	01	H5410_052_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	052	0	1	01	01	H5410_052_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.09	33						499.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	053	0	1	01	01	H5410_053_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	053	0	1	01	01	H5410_053_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	053	0	1	01	01	H5410_053_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	053	0	1	01	01	H5410_053_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	053	0	1	01	01	H5410_053_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					15.00	30.00	45.00											47.00	94.00	141.00				15.00	30.00	45.00				47.00				47.00			1.57	0.50		1.57	0.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	15.00	30.00	45.00	35.00	70.00	105.00	15.00	30.00	45.00	35.00		35.00
H5410	053	0	1	01	01	H5410_053_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	053	0	1	01	01	H5410_053_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											615.15	33						499.60	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5410	054	0	1	01	01	H5410_054_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H5410	054	0	1	01	01	H5410_054_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5410	054	0	1	01	01	H5410_054_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H5410	054	0	1	01	01	H5410_054_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5410	054	0	1	01	01	H5410_054_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	054	0	1	01	01	H5410_054_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5410	054	0	1	01	01	H5410_054_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.26	33						501.70	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5420	001	0	1	01	01	H5420_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	001	0	1	01	01	H5420_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5420	001	0	1	01	01	H5420_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	001	0	1	01	01	H5420_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5420	001	0	1	01	01	H5420_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H5420	001	0	1	01	01	H5420_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	65.00		195.00																											195.00						185.00				65.00				65.00		2.16						2.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5420	001	0	1	01	01	H5420_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				447.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	003	0	1	01	01	H5420_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	003	0	1	01	01	H5420_003_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5420	003	0	1	01	01	H5420_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	003	0	1	01	01	H5420_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5420	003	0	1	01	01	H5420_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	25.00		75.00																											75.00						65.00				25.00				25.00		0.83						0.80	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H5420	003	0	1	01	01	H5420_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5420	003	0	1	01	01	H5420_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				564.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	014	0	1	01	01	H5420_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	014	0	1	01	01	H5420_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5420	014	0	1	01	01	H5420_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5420	014	0	1	01	01	H5420_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5420	014	0	1	01	01	H5420_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00			0.00	0.00		0.00
H5420	014	0	1	01	01	H5420_014_0	5			Preferred Brand	4	11	1	2	3	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5420	014	0	1	01	01	H5420_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	65.00		195.00																											195.00						185.00				65.00				65.00		2.16						2.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5420	014	0	1	01	01	H5420_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				456.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5422	011	0	1	01	01	H5422_011_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	011	0	1	01	01	H5422_011_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								16.00	32.00	48.00					11.00	22.00	33.00					0.00	0.00	0.00																16.00				16.00			0.53	0.37	0.00			0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	011	0	1	01	01	H5422_011_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5422	011	0	1	01	01	H5422_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	011	0	1	01	01	H5422_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	011	0	1	01	01	H5422_011_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	011	0	1	01	01	H5422_011_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5422	013	0	1	01	01	H5422_013_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					5.00	15.00	15.00																10.00				10.00			0.33	0.17	0.17			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	013	0	1	01	01	H5422_013_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					15.00	45.00	45.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	013	0	1	01	01	H5422_013_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5422	013	0	1	01	01	H5422_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	013	0	1	01	01	H5422_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	013	0	1	01	01	H5422_013_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								5.00	10.00	15.00					5.00	10.00	15.00					5.00	15.00	15.00																5.00				5.00			0.17	0.17	0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	015	0	1	01	01	H5422_015_0	5			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	015	0	1	01	01	H5422_015_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	015	0	1	01	01	H5422_015_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5422	015	0	1	01	01	H5422_015_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	015	0	1	01	01	H5422_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	015	0	1	01	01	H5422_015_0	5			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5422	015	0	1	01	01	H5422_015_0	5			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	001	0	1	01	01	H5425_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	001	0	1	01	01	H5425_001_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	001	0	1	01	01	H5425_001_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	001	0	1	01	01	H5425_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	001	0	1	01	01	H5425_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	001	0	1	01	01	H5425_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	001	0	1	01	01	H5425_001_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	004	0	1	01	01	H5425_004_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	004	0	1	01	01	H5425_004_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	004	0	1	01	01	H5425_004_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					3.00	6.00	6.00											12.00	24.00	24.00				3.00	6.00	0.00				12.00				12.00			0.40	0.10		0.40	0.10	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	004	0	1	01	01	H5425_004_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					3.00	6.00	6.00											12.00	24.00	24.00				3.00	6.00	0.00				12.00				12.00			0.40	0.10		0.40	0.10	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	004	0	1	01	01	H5425_004_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	004	0	1	01	01	H5425_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	004	0	1	01	01	H5425_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	004	0	1	01	01	H5425_004_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	005	0	1	01	01	H5425_005_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	005	0	1	01	01	H5425_005_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	005	0	1	01	01	H5425_005_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					5.00	10.00	10.00											15.00	30.00	30.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	005	0	1	01	01	H5425_005_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					42.00	84.00	106.00											47.00	94.00	121.00				42.00	84.00	106.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	005	0	1	01	01	H5425_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	005	0	1	01	01	H5425_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	005	0	1	01	01	H5425_005_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	006	0	1	01	01	H5425_006_0	10			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	006	0	1	01	01	H5425_006_0	10			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	006	0	1	01	01	H5425_006_0	10			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	006	0	1	01	01	H5425_006_0	10			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	006	0	1	01	01	H5425_006_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	006	0	1	01	01	H5425_006_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	006	0	1	01	01	H5425_006_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	006	0	1	01	01	H5425_006_0	10			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	007	0	1	01	01	H5425_007_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	007	0	1	01	01	H5425_007_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	007	0	1	01	01	H5425_007_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	007	0	1	01	01	H5425_007_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	007	0	1	01	01	H5425_007_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	007	0	1	01	01	H5425_007_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	007	0	1	01	01	H5425_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	007	0	1	01	01	H5425_007_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	008	0	1	01	01	H5425_008_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	008	0	1	01	01	H5425_008_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	008	0	1	01	01	H5425_008_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	008	0	1	01	01	H5425_008_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	008	0	1	01	01	H5425_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	008	0	1	01	01	H5425_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	008	0	1	01	01	H5425_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	008	0	1	01	01	H5425_008_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	009	0	1	01	01	H5425_009_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	009	0	1	01	01	H5425_009_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	009	0	1	01	01	H5425_009_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	009	0	1	01	01	H5425_009_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	009	0	1	01	01	H5425_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	009	0	1	01	01	H5425_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	009	0	1	01	01	H5425_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	009	0	1	01	01	H5425_009_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	019	0	1	01	01	H5425_019_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	019	0	1	01	01	H5425_019_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	019	0	1	01	01	H5425_019_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					42.00	84.00	106.00											47.00	94.00	121.00				42.00	84.00	106.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	019	0	1	01	01	H5425_019_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	019	0	1	01	01	H5425_019_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	019	0	1	01	01	H5425_019_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	020	0	1	01	01	H5425_020_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	020	0	1	01	01	H5425_020_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	020	0	1	01	01	H5425_020_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					42.00	84.00	106.00											47.00	94.00	121.00				42.00	84.00	106.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	020	0	1	01	01	H5425_020_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	020	0	1	01	01	H5425_020_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	020	0	1	01	01	H5425_020_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	028	0	1	01	01	H5425_028_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	028	0	1	01	01	H5425_028_0	9			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	028	0	1	01	01	H5425_028_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	028	0	1	01	01	H5425_028_0	9			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	028	0	1	01	01	H5425_028_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	028	0	1	01	01	H5425_028_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	028	0	1	01	01	H5425_028_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	028	0	1	01	01	H5425_028_0	9			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	033	0	1	01	01	H5425_033_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	033	0	1	01	01	H5425_033_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	033	0	1	01	01	H5425_033_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	28.00					0.00	0.00	0.00											14.00	28.00	28.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	033	0	1	01	01	H5425_033_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	28.00					0.00	0.00	0.00											14.00	28.00	28.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	033	0	1	01	01	H5425_033_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	033	0	1	01	01	H5425_033_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	033	0	1	01	01	H5425_033_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	033	0	1	01	01	H5425_033_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	034	0	1	01	01	H5425_034_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	034	0	1	01	01	H5425_034_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	034	0	1	01	01	H5425_034_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	034	0	1	01	01	H5425_034_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	034	0	1	01	01	H5425_034_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								35.00	70.00	85.00					30.00	60.00	70.00											35.00	70.00	85.00				30.00	60.00	70.00				35.00				35.00			1.17	1.00		1.17	1.00	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	034	0	1	01	01	H5425_034_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	034	0	1	01	01	H5425_034_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	034	0	1	01	01	H5425_034_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	055	0	1	01	01	H5425_055_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	055	0	1	01	01	H5425_055_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	055	0	1	01	01	H5425_055_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					5.00	10.00	10.00											12.00	24.00	24.00				5.00	10.00	0.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	055	0	1	01	01	H5425_055_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					42.00	84.00	106.00											47.00	94.00	121.00				42.00	84.00	106.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	055	0	1	01	01	H5425_055_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	055	0	1	01	01	H5425_055_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	055	0	1	01	01	H5425_055_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	065	0	1	01	01	H5425_065_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	065	0	1	01	01	H5425_065_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	065	0	1	01	01	H5425_065_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	065	0	1	01	01	H5425_065_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	065	0	1	01	01	H5425_065_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	065	0	1	01	01	H5425_065_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	065	0	1	01	01	H5425_065_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	065	0	1	01	01	H5425_065_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	066	0	1	01	01	H5425_066_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	066	0	1	01	01	H5425_066_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	066	0	1	01	01	H5425_066_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	066	0	1	01	01	H5425_066_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	066	0	1	01	01	H5425_066_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	066	0	1	01	01	H5425_066_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	066	0	1	01	01	H5425_066_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	066	0	1	01	01	H5425_066_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	067	0	1	01	01	H5425_067_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	067	0	1	01	01	H5425_067_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	067	0	1	01	01	H5425_067_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	28.00					0.00	0.00	0.00											14.00	28.00	28.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	067	0	1	01	01	H5425_067_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	28.00					0.00	0.00	0.00											14.00	28.00	28.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	067	0	1	01	01	H5425_067_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	067	0	1	01	01	H5425_067_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	067	0	1	01	01	H5425_067_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	067	0	1	01	01	H5425_067_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	068	0	1	01	01	H5425_068_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	068	0	1	01	01	H5425_068_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	068	0	1	01	01	H5425_068_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	28.00					0.00	0.00	0.00											14.00	28.00	28.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	068	0	1	01	01	H5425_068_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	28.00					0.00	0.00	0.00											14.00	28.00	28.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	068	0	1	01	01	H5425_068_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	068	0	1	01	01	H5425_068_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	068	0	1	01	01	H5425_068_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	068	0	1	01	01	H5425_068_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	069	0	1	01	01	H5425_069_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	069	0	1	01	01	H5425_069_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	069	0	1	01	01	H5425_069_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	069	0	1	01	01	H5425_069_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	069	0	1	01	01	H5425_069_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	069	0	1	01	01	H5425_069_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	069	0	1	01	01	H5425_069_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	069	0	1	01	01	H5425_069_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	070	0	1	01	01	H5425_070_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	070	0	1	01	01	H5425_070_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	070	0	1	01	01	H5425_070_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	070	0	1	01	01	H5425_070_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	070	0	1	01	01	H5425_070_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								45.00	90.00	115.00					35.00	70.00	85.00											45.00	90.00	115.00				35.00	70.00	85.00				45.00				45.00			1.50	1.17		1.50	1.17	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	070	0	1	01	01	H5425_070_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								95.00	190.00	265.00					85.00	170.00	235.00											95.00	190.00	265.00				85.00	170.00	235.00				95.00				95.00			3.17	2.83		3.17	2.83	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	070	0	1	01	01	H5425_070_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	070	0	1	01	01	H5425_070_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	073	0	1	01	01	H5425_073_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	073	0	1	01	01	H5425_073_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								17.50	35.00	35.00					0.00	0.00	0.00											17.50	35.00	35.00				0.00	0.00	0.00				17.50				17.50			0.58	0.00		0.58	0.00	0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	073	0	1	01	01	H5425_073_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								45.00	90.00	115.00					40.00	80.00	100.00											45.00	90.00	115.00				40.00	80.00	100.00				45.00				45.00			1.50	1.33		1.50	1.33	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	073	0	1	01	01	H5425_073_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								95.00	190.00	265.00					90.00	180.00	250.00											95.00	190.00	265.00				90.00	180.00	250.00				95.00				95.00			3.17	3.00		3.17	3.00	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	073	0	1	01	01	H5425_073_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	073	0	1	01	01	H5425_073_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	075	0	1	01	01	H5425_075_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	075	0	1	01	01	H5425_075_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	075	0	1	01	01	H5425_075_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	075	0	1	01	01	H5425_075_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	075	0	1	01	01	H5425_075_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	075	0	1	01	01	H5425_075_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	075	0	1	01	01	H5425_075_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	075	0	1	01	01	H5425_075_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	076	0	1	01	01	H5425_076_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	076	0	1	01	01	H5425_076_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	076	0	1	01	01	H5425_076_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	076	0	1	01	01	H5425_076_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	076	0	1	01	01	H5425_076_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	076	0	1	01	01	H5425_076_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	076	0	1	01	01	H5425_076_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	076	0	1	01	01	H5425_076_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	077	0	1	01	01	H5425_077_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	077	0	1	01	01	H5425_077_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	077	0	1	01	01	H5425_077_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	077	0	1	01	01	H5425_077_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	077	0	1	01	01	H5425_077_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	077	0	1	01	01	H5425_077_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	077	0	1	01	01	H5425_077_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	077	0	1	01	01	H5425_077_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	078	0	1	01	01	H5425_078_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	078	0	1	01	01	H5425_078_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	078	0	1	01	01	H5425_078_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	078	0	1	01	01	H5425_078_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	078	0	1	01	01	H5425_078_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	078	0	1	01	01	H5425_078_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	078	0	1	01	01	H5425_078_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	082	0	1	01	01	H5425_082_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	082	0	1	01	01	H5425_082_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	082	0	1	01	01	H5425_082_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	082	0	1	01	01	H5425_082_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	082	0	1	01	01	H5425_082_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	082	0	1	01	01	H5425_082_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	082	0	1	01	01	H5425_082_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	082	0	1	01	01	H5425_082_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	083	0	1	01	01	H5425_083_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	083	0	1	01	01	H5425_083_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	083	0	1	01	01	H5425_083_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	083	0	1	01	01	H5425_083_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					37.00	74.00	91.00											47.00	94.00	121.00				37.00	74.00	91.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	083	0	1	01	01	H5425_083_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	083	0	1	01	01	H5425_083_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	083	0	1	01	01	H5425_083_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	084	0	1	01	01	H5425_084_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	084	0	1	01	01	H5425_084_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	084	0	1	01	01	H5425_084_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	084	0	1	01	01	H5425_084_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	084	0	1	01	01	H5425_084_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	084	0	1	01	01	H5425_084_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	084	0	1	01	01	H5425_084_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	085	0	1	01	01	H5425_085_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	085	0	1	01	01	H5425_085_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	085	0	1	01	01	H5425_085_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	085	0	1	01	01	H5425_085_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	085	0	1	01	01	H5425_085_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	085	0	1	01	01	H5425_085_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	085	0	1	01	01	H5425_085_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	086	0	1	01	01	H5425_086_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	086	0	1	01	01	H5425_086_0	9			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	086	0	1	01	01	H5425_086_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	086	0	1	01	01	H5425_086_0	9			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	086	0	1	01	01	H5425_086_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								37.00	74.00	91.00					37.00	74.00	91.00											37.00	74.00	91.00				37.00	74.00	91.00				37.00				37.00			1.23	1.23		1.23	1.23	1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	086	0	1	01	01	H5425_086_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					99.00	198.00	277.00											100.00	200.00	280.00				99.00	198.00	277.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	086	0	1	01	01	H5425_086_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	086	0	1	01	01	H5425_086_0	9			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	087	0	1	01	01	H5425_087_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	087	0	1	01	01	H5425_087_0	9			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	087	0	1	01	01	H5425_087_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	087	0	1	01	01	H5425_087_0	9			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	087	0	1	01	01	H5425_087_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								37.00	74.00	91.00					37.00	74.00	91.00											37.00	74.00	91.00				37.00	74.00	91.00				37.00				37.00			1.23	1.23		1.23	1.23	1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	087	0	1	01	01	H5425_087_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					99.00	198.00	277.00											100.00	200.00	280.00				99.00	198.00	277.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	087	0	1	01	01	H5425_087_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	087	0	1	01	01	H5425_087_0	9			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	091	0	1	01	01	H5425_091_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	091	0	1	01	01	H5425_091_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	091	0	1	01	01	H5425_091_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	091	0	1	01	01	H5425_091_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	091	0	1	01	01	H5425_091_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								37.00	74.00	91.00					37.00	74.00	91.00											37.00	74.00	91.00				37.00	74.00	91.00				37.00				37.00			1.23	1.23		1.23	1.23	1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	091	0	1	01	01	H5425_091_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					99.00	198.00	277.00											100.00	200.00	280.00				99.00	198.00	277.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	091	0	1	01	01	H5425_091_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	091	0	1	01	01	H5425_091_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	092	0	1	01	01	H5425_092_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	092	0	1	01	01	H5425_092_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	092	0	1	01	01	H5425_092_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	092	0	1	01	01	H5425_092_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	092	0	1	01	01	H5425_092_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	092	0	1	01	01	H5425_092_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	092	0	1	01	01	H5425_092_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	092	0	1	01	01	H5425_092_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	096	0	1	01	01	H5425_096_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	096	0	1	01	01	H5425_096_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	096	0	1	01	01	H5425_096_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	096	0	1	01	01	H5425_096_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	096	0	1	01	01	H5425_096_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	096	0	1	01	01	H5425_096_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	096	0	1	01	01	H5425_096_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	096	0	1	01	01	H5425_096_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	100	0	1	01	01	H5425_100_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	100	0	1	01	01	H5425_100_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	100	0	1	01	01	H5425_100_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	100	0	1	01	01	H5425_100_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	100	0	1	01	01	H5425_100_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	100	0	1	01	01	H5425_100_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	100	0	1	01	01	H5425_100_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	100	0	1	01	01	H5425_100_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	101	0	1	01	01	H5425_101_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	101	0	1	01	01	H5425_101_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	101	0	1	01	01	H5425_101_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	101	0	1	01	01	H5425_101_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	101	0	1	01	01	H5425_101_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	101	0	1	01	01	H5425_101_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	101	0	1	01	01	H5425_101_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	101	0	1	01	01	H5425_101_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	102	0	1	01	01	H5425_102_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	102	0	1	01	01	H5425_102_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	102	0	1	01	01	H5425_102_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	102	0	1	01	01	H5425_102_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	102	0	1	01	01	H5425_102_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	102	0	1	01	01	H5425_102_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	102	0	1	01	01	H5425_102_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	102	0	1	01	01	H5425_102_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	103	0	1	01	01	H5425_103_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	103	0	1	01	01	H5425_103_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	103	0	1	01	01	H5425_103_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	103	0	1	01	01	H5425_103_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	103	0	1	01	01	H5425_103_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	103	0	1	01	01	H5425_103_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	103	0	1	01	01	H5425_103_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	103	0	1	01	01	H5425_103_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	104	0	1	01	01	H5425_104_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	104	0	1	01	01	H5425_104_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	104	0	1	01	01	H5425_104_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	104	0	1	01	01	H5425_104_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	104	0	1	01	01	H5425_104_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								35.00	70.00	85.00					30.00	60.00	70.00											35.00	70.00	85.00				30.00	60.00	70.00				35.00				35.00			1.17	1.00		1.17	1.00	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	104	0	1	01	01	H5425_104_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	104	0	1	01	01	H5425_104_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	104	0	1	01	01	H5425_104_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	105	0	1	01	01	H5425_105_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	105	0	1	01	01	H5425_105_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	105	0	1	01	01	H5425_105_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	105	0	1	01	01	H5425_105_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	105	0	1	01	01	H5425_105_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								35.00	70.00	85.00					30.00	60.00	70.00											35.00	70.00	85.00				30.00	60.00	70.00				35.00				35.00			1.17	1.00		1.17	1.00	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	105	0	1	01	01	H5425_105_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	105	0	1	01	01	H5425_105_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	105	0	1	01	01	H5425_105_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	106	0	1	01	01	H5425_106_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	106	0	1	01	01	H5425_106_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	106	0	1	01	01	H5425_106_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	106	0	1	01	01	H5425_106_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	106	0	1	01	01	H5425_106_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								45.00	90.00	115.00					35.00	70.00	85.00											45.00	90.00	115.00				35.00	70.00	85.00				45.00				45.00			1.50	1.17		1.50	1.17	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H5425	106	0	1	01	01	H5425_106_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								95.00	190.00	265.00					85.00	170.00	235.00											95.00	190.00	265.00				85.00	170.00	235.00				95.00				95.00			3.17	2.83		3.17	2.83	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	106	0	1	01	01	H5425_106_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	106	0	1	01	01	H5425_106_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	107	0	1	01	01	H5425_107_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	107	0	1	01	01	H5425_107_0	8			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	107	0	1	01	01	H5425_107_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	107	0	1	01	01	H5425_107_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	107	0	1	01	01	H5425_107_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	107	0	1	01	01	H5425_107_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	107	0	1	01	01	H5425_107_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	108	0	1	01	01	H5425_108_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	108	0	1	01	01	H5425_108_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	108	0	1	01	01	H5425_108_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	108	0	1	01	01	H5425_108_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	35.00	70.00	85.00																			35.00	70.00	85.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00	50.00	55.00				25.00	50.00	55.00				25.00		25.00
H5425	108	0	1	01	01	H5425_108_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	70.00	140.00	190.00																			70.00	140.00	190.00																70.00				70.00		2.33			2.33			2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	108	0	1	01	01	H5425_108_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	108	0	1	01	01	H5425_108_0	8			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	22.00	33.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	109	0	1	01	01	H5425_109_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	109	0	1	01	01	H5425_109_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	109	0	1	01	01	H5425_109_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	109	0	1	01	01	H5425_109_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	35.00	70.00	85.00																			35.00	70.00	85.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00	50.00	55.00				25.00	50.00	55.00				25.00		25.00
H5425	109	0	1	01	01	H5425_109_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	70.00	140.00	190.00																			70.00	140.00	190.00																70.00				70.00		2.33			2.33			2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	109	0	1	01	01	H5425_109_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	109	0	1	01	01	H5425_109_0	8			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	22.00	33.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	110	0	1	01	01	H5425_110_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	110	0	1	01	01	H5425_110_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	110	0	1	01	01	H5425_110_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	110	0	1	01	01	H5425_110_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	35.00	70.00	85.00																			35.00	70.00	85.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00	50.00	55.00				25.00	50.00	55.00				25.00		25.00
H5425	110	0	1	01	01	H5425_110_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	70.00	140.00	190.00																			70.00	140.00	190.00																70.00				70.00		2.33			2.33			2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	110	0	1	01	01	H5425_110_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	110	0	1	01	01	H5425_110_0	8			Select Care Drugs	4	10	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	22.00	33.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	111	0	1	01	01	H5425_111_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	111	0	1	01	01	H5425_111_0	8			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	111	0	1	01	01	H5425_111_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	111	0	1	01	01	H5425_111_0	8			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	111	0	1	01	01	H5425_111_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	111	0	1	01	01	H5425_111_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	111	0	1	01	01	H5425_111_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	111	0	1	01	01	H5425_111_0	8			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	112	0	1	01	01	H5425_112_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	112	0	1	01	01	H5425_112_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	112	0	1	01	01	H5425_112_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	112	0	1	01	01	H5425_112_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	112	0	1	01	01	H5425_112_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	112	0	1	01	01	H5425_112_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	112	0	1	01	01	H5425_112_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	112	0	1	01	01	H5425_112_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	115	0	1	01	01	H5425_115_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	115	0	1	01	01	H5425_115_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	115	0	1	01	01	H5425_115_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	115	0	1	01	01	H5425_115_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	115	0	1	01	01	H5425_115_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	115	0	1	01	01	H5425_115_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	115	0	1	01	01	H5425_115_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	115	0	1	01	01	H5425_115_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	116	0	1	01	01	H5425_116_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	116	0	1	01	01	H5425_116_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5425	116	0	1	01	01	H5425_116_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	116	0	1	01	01	H5425_116_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5425	116	0	1	01	01	H5425_116_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					35.00	70.00	85.00											47.00	94.00	121.00				35.00	70.00	85.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H5425	116	0	1	01	01	H5425_116_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	116	0	1	01	01	H5425_116_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5425	116	0	1	01	01	H5425_116_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5427	059	0	1	01	01	H5427_059_0	8			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	059	0	1	01	01	H5427_059_0	8			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	059	0	1	01	01	H5427_059_0	8			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5427	059	0	1	01	01	H5427_059_0	8			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	059	0	1	01	01	H5427_059_0	8			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	060	0	1	01	01	H5427_060_0	8			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	060	0	1	01	01	H5427_060_0	8			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	060	0	1	01	01	H5427_060_0	8			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5427	060	0	1	01	01	H5427_060_0	8			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5427	060	0	1	01	01	H5427_060_0	8			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	070	0	1	01	01	H5427_070_0	10			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5427	070	0	1	01	01	H5427_070_0	10			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5427	070	0	1	01	01	H5427_070_0	10			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													15.00		45.00				15.00		30.00				15		15
H5427	070	0	1	01	01	H5427_070_0	10			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	55.00		165.00																			55.00		110.00																55.00				55.00		1.83			1.83			1.62	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35		35
H5427	070	0	1	01	01	H5427_070_0	10			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5427	070	0	1	01	01	H5427_070_0	10			Select Diabetic Drugs	4	11	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5427	070	0	1	01	01	H5427_070_0	10			Select Diabetic Drugs	4	11	1	2	5	3	110		01	110		1	30		90				1	2	30		90				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H5427	072	0	1	01	01	H5427_072_0	8			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5427	072	0	1	01	01	H5427_072_0	8			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5427	072	0	1	01	01	H5427_072_0	8			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	20.00		60.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													20.00		60.00				20.00		40.00				20.00		20.00
H5427	072	0	1	01	01	H5427_072_0	8			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35.00		35.00
H5427	072	0	1	01	01	H5427_072_0	8			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5427	072	0	1	01	01	H5427_072_0	8			Select Diabetic Drugs	4	11	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		30.00				10.00		20.00				10.00		10.00
H5427	072	0	1	01	01	H5427_072_0	8			Select Diabetic Drugs	4	11	1	2	5	3	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H5427	077	0	1	01	01	H5427_077_0	8			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	077	0	1	01	01	H5427_077_0	8			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	077	0	1	01	01	H5427_077_0	8			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	20.00		60.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		40.00				20.00		20.00
H5427	077	0	1	01	01	H5427_077_0	8			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5427	077	0	1	01	01	H5427_077_0	8			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	078	0	1	01	01	H5427_078_0	10		N	Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	15.00		45.00																			15.00		45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		45.00				15.00		15.00
H5427	078	0	1	01	01	H5427_078_0	10		N	Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	45.00		135.00																			45.00		135.00																45.00				45.00		1.50			1.50			1.32	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H5427	078	0	1	01	01	H5427_078_0	10		N	Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	95.00		285.00																			95.00		285.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	078	0	1	01	01	H5427_078_0	10		N	Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	082	0	1	01	01	H5427_082_0	8			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5427	082	0	1	01	01	H5427_082_0	8			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5427	082	0	1	01	01	H5427_082_0	8			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													30.00		90.00				30.00		60.00				30		30
H5427	082	0	1	01	01	H5427_082_0	8			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	80.00		240.00																			80.00		160.00																80.00				80.00		2.67			2.67			2.35	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		105.00				35		35
H5427	082	0	1	01	01	H5427_082_0	8			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5427	082	0	1	01	01	H5427_082_0	8			Select Diabetic Drugs	4	11	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		30.00				10.00		20.00				10		10
H5427	083	0	1	01	01	H5427_083_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	083	0	1	01	01	H5427_083_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	083	0	1	01	01	H5427_083_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5427	083	0	1	01	01	H5427_083_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	80.00		240.00																			80.00		160.00																80.00				80.00		2.67			2.67			2.35	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	083	0	1	01	01	H5427_083_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	087	0	1	01	01	H5427_087_0	9		N	Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	15.00		45.00																			15.00		45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		45.00				15.00		15.00
H5427	087	0	1	01	01	H5427_087_0	9		N	Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	45.00		135.00																			45.00		135.00																45.00				45.00		1.50			1.50			1.32	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H5427	087	0	1	01	01	H5427_087_0	9		N	Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	95.00		285.00																			95.00		285.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	087	0	1	01	01	H5427_087_0	9		N	Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	088	0	1	01	01	H5427_088_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	088	0	1	01	01	H5427_088_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	088	0	1	01	01	H5427_088_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5427	088	0	1	01	01	H5427_088_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	75.00		225.00																			75.00		150.00																75.00				75.00		2.50			2.50			2.21	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	088	0	1	01	01	H5427_088_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	089	0	1	01	01	H5427_089_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	089	0	1	01	01	H5427_089_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	089	0	1	01	01	H5427_089_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	25.00		75.00																			25.00		50.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		50.00				25		25
H5427	089	0	1	01	01	H5427_089_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	65.00		195.00																			65.00		130.00																65.00				65.00		2.17			2.17			1.91	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	089	0	1	01	01	H5427_089_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	091	0	1	01	01	H5427_091_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	091	0	1	01	01	H5427_091_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	091	0	1	01	01	H5427_091_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	25.00		75.00																			25.00		50.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		50.00				25		25
H5427	091	0	1	01	01	H5427_091_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	091	0	1	01	01	H5427_091_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	092	0	1	01	01	H5427_092_0	8			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	092	0	1	01	01	H5427_092_0	8			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	092	0	1	01	01	H5427_092_0	8			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10		10
H5427	092	0	1	01	01	H5427_092_0	8			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	55.00		165.00																			55.00		110.00																55.00				55.00		1.83			1.83			1.62	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	092	0	1	01	01	H5427_092_0	8			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	093	0	1	01	01	H5427_093_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	093	0	1	01	01	H5427_093_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	093	0	1	01	01	H5427_093_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5427	093	0	1	01	01	H5427_093_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	093	0	1	01	01	H5427_093_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	094	0	1	01	01	H5427_094_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	094	0	1	01	01	H5427_094_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	094	0	1	01	01	H5427_094_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	25.00		75.00																			25.00		50.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		50.00				25		25
H5427	094	0	1	01	01	H5427_094_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	094	0	1	01	01	H5427_094_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	096	0	1	01	01	H5427_096_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	096	0	1	01	01	H5427_096_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	096	0	1	01	01	H5427_096_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	096	0	1	01	01	H5427_096_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	098	0	1	01	01	H5427_098_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	098	0	1	01	01	H5427_098_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	098	0	1	01	01	H5427_098_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5427	098	0	1	01	01	H5427_098_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	098	0	1	01	01	H5427_098_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	099	0	1	01	01	H5427_099_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5427	099	0	1	01	01	H5427_099_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5427	099	0	1	01	01	H5427_099_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													30.00		90.00				30.00		60.00				30		30
H5427	099	0	1	01	01	H5427_099_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35		35
H5427	099	0	1	01	01	H5427_099_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5427	099	0	1	01	01	H5427_099_0	7			Select Diabetic Drugs	4	11	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		30.00				10.00		20.00				10		10
H5427	099	0	1	01	01	H5427_099_0	7			Select Diabetic Drugs	4	11	1	2	5	3	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H5427	102	0	1	01	01	H5427_102_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	102	0	1	01	01	H5427_102_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	102	0	1	01	01	H5427_102_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	102	0	1	01	01	H5427_102_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	103	0	1	01	01	H5427_103_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	103	0	1	01	01	H5427_103_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	103	0	1	01	01	H5427_103_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	103	0	1	01	01	H5427_103_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	104	0	1	01	01	H5427_104_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	104	0	1	01	01	H5427_104_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	104	0	1	01	01	H5427_104_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	20.00		60.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		40.00				20		20
H5427	104	0	1	01	01	H5427_104_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	104	0	1	01	01	H5427_104_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	105	0	1	01	01	H5427_105_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	105	0	1	01	01	H5427_105_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	105	0	1	01	01	H5427_105_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	105	0	1	01	01	H5427_105_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	106	0	1	01	01	H5427_106_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	106	0	1	01	01	H5427_106_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5427	106	0	1	01	01	H5427_106_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	80.00		240.00																			80.00		160.00																80.00				80.00		2.67			2.67			2.35	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	106	0	1	01	01	H5427_106_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	107	0	1	01	01	H5427_107_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	107	0	1	01	01	H5427_107_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5427	107	0	1	01	01	H5427_107_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	107	0	1	01	01	H5427_107_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	108	0	1	01	01	H5427_108_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5427	108	0	1	01	01	H5427_108_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5427	108	0	1	01	01	H5427_108_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													30.00		90.00				30.00		60.00				30		30
H5427	108	0	1	01	01	H5427_108_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	80.00		240.00																			80.00		160.00																80.00				80.00		2.67			2.67			2.35	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35		35
H5427	108	0	1	01	01	H5427_108_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5427	108	0	1	01	01	H5427_108_0	6			Select Diabetic Drugs	4	10	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		30.00				10.00		20.00				10		10
H5427	109	0	1	01	01	H5427_109_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	109	0	1	01	01	H5427_109_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	109	0	1	01	01	H5427_109_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	25.00		75.00																			25.00		50.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		50.00				25		25
H5427	109	0	1	01	01	H5427_109_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	109	0	1	01	01	H5427_109_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	110	0	1	01	01	H5427_110_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	110	0	1	01	01	H5427_110_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	110	0	1	01	01	H5427_110_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	20.00		60.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		40.00				20		20
H5427	110	0	1	01	01	H5427_110_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	110	0	1	01	01	H5427_110_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	111	0	1	01	01	H5427_111_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	111	0	1	01	01	H5427_111_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	111	0	1	01	01	H5427_111_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	25.00		75.00																			25.00		50.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00				25.00		50.00				25		25
H5427	111	0	1	01	01	H5427_111_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	65.00		195.00																			65.00		130.00																65.00				65.00		2.17			2.17			1.91	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5427	111	0	1	01	01	H5427_111_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	112	0	1	02	01	H5427_112_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	112	0	1	02	01	H5427_112_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H5427	112	0	1	02	01	H5427_112_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	112	0	1	02	01	H5427_112_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	113	0	1	02	01	H5427_113_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5427	113	0	1	02	01	H5427_113_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5427	113	0	1	02	01	H5427_113_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30.00		30.00
H5427	113	0	1	02	01	H5427_113_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5427	113	0	1	02	01	H5427_113_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5431	001	0	1	01	01	H5431_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	001	0	1	01	01	H5431_001_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	001	0	1	01	01	H5431_001_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	001	0	1	01	01	H5431_001_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	001	0	1	01	01	H5431_001_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								20.00							0.00							0.00																		20.00				20.00			0.67	0.00	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00			0.00			0.00						0		0
H5431	001	0	1	01	01	H5431_001_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								35.00							25.00							25.00																		35.00				35.00			1.17	0.83	0.83			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	001	0	1	01	01	H5431_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	001	0	1	01	01	H5431_001_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	006	0	1	01	01	H5431_006_0	6			Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				1.62	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	006	0	1	01	01	H5431_006_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.03	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	006	0	1	01	01	H5431_006_0	6			Preferred Brand	4	11	1	1	3	1	010		01	010		1	30								30						30		34				95.15	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00						35.00						35		35
H5431	006	0	1	01	01	H5431_006_0	6			Non-Preferred Brand	4	11	1	1	4	1	010		01	010		1	30								30						30		34				102.06	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	006	0	1	01	01	H5431_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	006	0	1	01	01	H5431_006_0	6			Supplemental Drugs	4	01	2	2	6	1	010		01	010		1	30								30						30		34	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	012	0	1	01	01	H5431_012_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	012	0	1	01	01	H5431_012_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	012	0	1	01	01	H5431_012_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	012	0	1	01	01	H5431_012_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	012	0	1	01	01	H5431_012_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								20.00							0.00							0.00																		20.00				20.00			0.67	0.00	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00			0.00			0.00						0		0
H5431	012	0	1	01	01	H5431_012_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								35.00							30.00							30.00																		35.00				35.00			1.17	1.00	1.00			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	012	0	1	01	01	H5431_012_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	012	0	1	01	01	H5431_012_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	013	0	1	01	01	H5431_013_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	013	0	1	01	01	H5431_013_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	013	0	1	01	01	H5431_013_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	013	0	1	01	01	H5431_013_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	013	0	1	01	01	H5431_013_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								20.00							15.00							15.00																		20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													15.00			15.00			15.00						15		15
H5431	013	0	1	01	01	H5431_013_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								35.00							30.00							30.00																		35.00				35.00			1.17	1.00	1.00			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	013	0	1	01	01	H5431_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	013	0	1	01	01	H5431_013_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	016	0	1	01	01	H5431_016_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				1.59	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	016	0	1	01	01	H5431_016_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.94	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	016	0	1	01	01	H5431_016_0	6		N	Preferred Brand	4	11	1	1	3	1	010		01	010		1	30								30						30		34				101.17	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00						35.00						35		35
H5431	016	0	1	01	01	H5431_016_0	6		N	Non-Preferred Brand	4	11	1	1	4	1	010		01	010		1	30								30						30		34				98.22	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	016	0	1	01	01	H5431_016_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	016	0	1	01	01	H5431_016_0	6		N	Supplemental Drugs	4	01	2	2	6	1	010		01	010		1	30								30						30		34	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	017	0	1	01	01	H5431_017_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	017	0	1	01	01	H5431_017_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	017	0	1	01	01	H5431_017_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	017	0	1	01	01	H5431_017_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	017	0	1	01	01	H5431_017_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								47.00							42.00							42.00																		47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00			35.00			35.00						35		35
H5431	017	0	1	01	01	H5431_017_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	017	0	1	01	01	H5431_017_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	017	0	1	01	01	H5431_017_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	018	0	1	01	01	H5431_018_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	018	0	1	01	01	H5431_018_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	018	0	1	01	01	H5431_018_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	018	0	1	01	01	H5431_018_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	018	0	1	01	01	H5431_018_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								47.00							42.00							42.00																		47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00			35.00			35.00						35		35
H5431	018	0	1	01	01	H5431_018_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	018	0	1	01	01	H5431_018_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	018	0	1	01	01	H5431_018_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	019	0	1	01	01	H5431_019_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34				1.54	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	019	0	1	01	01	H5431_019_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.93	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	019	0	1	01	01	H5431_019_0	6		N	Preferred Brand	4	11	1	1	3	1	010		01	010		1	30								30						30		34				92.05	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00						35.00						35		35
H5431	019	0	1	01	01	H5431_019_0	6		N	Non-Preferred Brand	4	11	1	1	4	1	010		01	010		1	30								30						30		34				100.41	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	019	0	1	01	01	H5431_019_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	019	0	1	01	01	H5431_019_0	6		N	Supplemental Drugs	4	01	2	2	6	1	010		01	010		1	30								30						30		34	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	020	0	1	01	01	H5431_020_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	020	0	1	01	01	H5431_020_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	020	0	1	01	01	H5431_020_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	020	0	1	01	01	H5431_020_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	020	0	1	01	01	H5431_020_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								47.00							42.00							42.00																		47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00			35.00			35.00						35		35
H5431	020	0	1	01	01	H5431_020_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	020	0	1	01	01	H5431_020_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	020	0	1	01	01	H5431_020_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	021	0	1	01	01	H5431_021_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	021	0	1	01	01	H5431_021_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	021	0	1	01	01	H5431_021_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	021	0	1	01	01	H5431_021_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	021	0	1	01	01	H5431_021_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								42.00							37.00							37.00																		42.00				42.00			1.40	1.23	1.23			1.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00			35.00			35.00						35		35
H5431	021	0	1	01	01	H5431_021_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								90.00							85.00							85.00																		90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	021	0	1	01	01	H5431_021_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	021	0	1	01	01	H5431_021_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	022	0	1	01	01	H5431_022_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	022	0	1	01	01	H5431_022_0	6			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	022	0	1	01	01	H5431_022_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	022	0	1	01	01	H5431_022_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H5431	022	0	1	01	01	H5431_022_0	6			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								42.00							37.00							37.00																		42.00				42.00			1.40	1.23	1.23			1.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00			35.00			35.00						35		35
H5431	022	0	1	01	01	H5431_022_0	6			Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								90.00							85.00							85.00																		90.00				90.00			3.00	2.83	2.83			2.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	022	0	1	01	01	H5431_022_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5431	022	0	1	01	01	H5431_022_0	6			Supplemental Drugs	4	01	2	2	6	1		010	01	010		1				30					30						30		34								0.00							0.00							0.00																		0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5434	002	0	1	04	01	H5434_002_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	3.00		9.00																			3.00		9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	002	0	1	04	01	H5434_002_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	3.00		9.00																			3.00		9.00																3.00				3.00		0.00			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	002	0	1	04	01	H5434_002_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	002	0	1	04	01	H5434_002_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	002	0	1	04	01	H5434_002_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	002	0	1	04	01	H5434_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1353.35	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	002	0	1	04	01	H5434_002_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	002	0	1	04	01	H5434_002_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	023	0	1	04	01	H5434_023_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	023	0	1	04	01	H5434_023_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	023	0	1	04	01	H5434_023_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	023	0	1	04	01	H5434_023_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	023	0	1	04	01	H5434_023_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	023	0	1	04	01	H5434_023_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1448.36	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	023	0	1	04	01	H5434_023_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	023	0	1	04	01	H5434_023_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	024	0	1	04	01	H5434_024_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	024	0	1	04	01	H5434_024_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	024	0	1	04	01	H5434_024_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	024	0	1	04	01	H5434_024_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	024	0	1	04	01	H5434_024_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	024	0	1	04	01	H5434_024_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1611.54	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	024	0	1	04	01	H5434_024_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	024	0	1	04	01	H5434_024_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	025	0	1	04	01	H5434_025_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	025	0	1	04	01	H5434_025_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	025	0	1	04	01	H5434_025_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	5.00		15.00																			5.00		15.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	025	0	1	04	01	H5434_025_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	025	0	1	04	01	H5434_025_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	025	0	1	04	01	H5434_025_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1576.75	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	025	0	1	04	01	H5434_025_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	025	0	1	04	01	H5434_025_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	026	0	1	04	01	H5434_026_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	026	0	1	04	01	H5434_026_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	026	0	1	04	01	H5434_026_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	026	0	1	04	01	H5434_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	026	0	1	04	01	H5434_026_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1257.69	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	026	0	1	04	01	H5434_026_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	026	0	1	04	01	H5434_026_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	030	0	1	04	01	H5434_030_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	030	0	1	04	01	H5434_030_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	030	0	1	04	01	H5434_030_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	030	0	1	04	01	H5434_030_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	030	0	1	04	01	H5434_030_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1656.37	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	030	0	1	04	01	H5434_030_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	030	0	1	04	01	H5434_030_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	031	0	1	04	01	H5434_031_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	031	0	1	04	01	H5434_031_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	4.00		12.00																			4.00		12.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	031	0	1	04	01	H5434_031_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	031	0	1	04	01	H5434_031_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	031	0	1	04	01	H5434_031_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1619.06	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	031	0	1	04	01	H5434_031_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	031	0	1	04	01	H5434_031_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	032	0	1	04	01	H5434_032_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	2.00		6.00																			2.00		6.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	032	0	1	04	01	H5434_032_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	032	0	1	04	01	H5434_032_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	032	0	1	04	01	H5434_032_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	032	0	1	04	01	H5434_032_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1421.33	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	032	0	1	04	01	H5434_032_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	032	0	1	04	01	H5434_032_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	033	0	1	04	01	H5434_033_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	033	0	1	04	01	H5434_033_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	033	0	1	04	01	H5434_033_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	033	0	1	04	01	H5434_033_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	033	0	1	04	01	H5434_033_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1317.81	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	033	0	1	04	01	H5434_033_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	033	0	1	04	01	H5434_033_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	034	0	1	04	01	H5434_034_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	034	0	1	04	01	H5434_034_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	034	0	1	04	01	H5434_034_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	034	0	1	04	01	H5434_034_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	034	0	1	04	01	H5434_034_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1642.52	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	034	0	1	04	01	H5434_034_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	034	0	1	04	01	H5434_034_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	035	0	1	04	01	H5434_035_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	035	0	1	04	01	H5434_035_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	8.00		24.00																			8.00		24.00																8.00				8.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	035	0	1	04	01	H5434_035_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	035	0	1	04	01	H5434_035_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	035	0	1	04	01	H5434_035_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1892.04	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	035	0	1	04	01	H5434_035_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	035	0	1	04	01	H5434_035_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	036	0	1	04	01	H5434_036_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	036	0	1	04	01	H5434_036_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	036	0	1	04	01	H5434_036_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	036	0	1	04	01	H5434_036_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	036	0	1	04	01	H5434_036_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1756.94	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	036	0	1	04	01	H5434_036_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	036	0	1	04	01	H5434_036_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	039	0	1	04	01	H5434_039_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	039	0	1	04	01	H5434_039_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5434	039	0	1	04	01	H5434_039_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	8.00		24.00																			8.00		24.00																8.00				8.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	039	0	1	04	01	H5434_039_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	039	0	1	04	01	H5434_039_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H5434	039	0	1	04	01	H5434_039_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1453.18	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5434	039	0	1	04	01	H5434_039_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5434	039	0	1	04	01	H5434_039_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5435	024	0	1	09	04	H5435_024_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5435	024	0	1	09	04	H5435_024_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5435	024	0	1	09	04	H5435_024_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5435	024	0	1	09	04	H5435_024_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5435	024	0	1	09	04	H5435_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5435	024	0	1	09	04	H5435_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5439	011	0	1	04	01	H5439_011_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	011	0	1	04	01	H5439_011_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	011	0	1	04	01	H5439_011_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5439	011	0	1	04	01	H5439_011_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											74.58	50	50	50				74.58	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5439	011	0	1	04	01	H5439_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5439	011	0	1	04	01	H5439_011_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	011	0	1	04	01	H5439_011_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5439	015	0	1	04	01	H5439_015_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	015	0	1	04	01	H5439_015_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	015	0	1	04	01	H5439_015_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H5439	015	0	1	04	01	H5439_015_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.64	50	50	50				81.64	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5439	015	0	1	04	01	H5439_015_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H5439	015	0	1	04	01	H5439_015_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	015	0	1	04	01	H5439_015_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5439	017	0	1	04	01	H5439_017_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	017	0	1	04	01	H5439_017_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5439	017	0	1	04	01	H5439_017_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	017	0	1	04	01	H5439_017_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5439	017	0	1	04	01	H5439_017_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.32	50	50	50				85.32	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5439	017	0	1	04	01	H5439_017_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5439	017	0	1	04	01	H5439_017_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	017	0	1	04	01	H5439_017_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5439	019	0	1	04	01	H5439_019_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	019	0	1	04	01	H5439_019_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5439	019	0	1	04	01	H5439_019_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	019	0	1	04	01	H5439_019_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5439	019	0	1	04	01	H5439_019_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											86.47	50	50	50				86.47	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5439	019	0	1	04	01	H5439_019_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5439	019	0	1	04	01	H5439_019_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5439	019	0	1	04	01	H5439_019_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5447	001	0	1	01	01	H5447_001_0	6			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	001	0	1	01	01	H5447_001_0	6			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31	7.00	14.00	17.50																			7.00	14.00	17.50																	7.00			7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	001	0	1	01	01	H5447_001_0	6			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31	30.00	60.00	75.00																			30.00	60.00	75.00																	30.00			30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													30.00	60.00	75.00				30.00	60.00	75.00				30.00		30.00
H5447	001	0	1	01	01	H5447_001_0	6			Non-Preferred Brand	4	10	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				120.08	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	001	0	1	01	01	H5447_001_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1592.30	30																				30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	002	0	1	01	01	H5447_002_0	5		N	Preferred Generic	3	01	1	1	1	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				4.50	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	002	0	1	01	01	H5447_002_0	5		N	Generic	3	01	1	1	2	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				23.76	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	002	0	1	01	01	H5447_002_0	5		N	Preferred Brand	3	10	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				132.86	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	87.50				35.00	70.00	87.50				35.00		35.00
H5447	002	0	1	01	01	H5447_002_0	5		N	Non-Preferred Brand	3	10	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				124.47	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5447	002	0	1	01	01	H5447_002_0	5		N	Specialty Tier	3	11	1	1	5	1	010		10	010		1	30								30							29	31				1177.69	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5454	001	0	1	01	01	H5454_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	001	0	1	01	01	H5454_001_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	001	0	1	01	01	H5454_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H5454	001	0	1	01	01	H5454_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5454	001	0	1	01	01	H5454_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											958.36	33						958.36	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	002	0	1	01	01	H5454_002_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	002	0	1	01	01	H5454_002_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	002	0	1	01	01	H5454_002_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H5454	002	0	1	01	01	H5454_002_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5454	002	0	1	01	01	H5454_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											958.99	33						958.99	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	005	0	1	01	01	H5454_005_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	005	0	1	01	01	H5454_005_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	50.00					0.00	0.00	0.00											20.00	40.00	50.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	005	0	1	01	01	H5454_005_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H5454	005	0	1	01	01	H5454_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5454	005	0	1	01	01	H5454_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.82	29						589.82	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	006	0	1	01	01	H5454_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	006	0	1	01	01	H5454_006_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	50.00					0.00	0.00	0.00											20.00	40.00	50.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5454	006	0	1	01	01	H5454_006_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H5454	006	0	1	01	01	H5454_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5454	006	0	1	01	01	H5454_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.82	29						589.82	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5471	064	0	1	01	01	H5471_064_0	13		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	064	0	1	01	01	H5471_064_0	13		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	064	0	1	01	01	H5471_064_0	13		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	064	0	1	01	01	H5471_064_0	13		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	064	0	1	01	01	H5471_064_0	13		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	065	0	1	01	01	H5471_065_0	9			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	065	0	1	01	01	H5471_065_0	9			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	065	0	1	01	01	H5471_065_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	065	0	1	01	01	H5471_065_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	065	0	1	01	01	H5471_065_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	065	0	1	01	01	H5471_065_0	9			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	5.00																					5.00																		5.00				5.00		0.17			0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00						5.00						5.00		5.00
H5471	065	0	1	01	01	H5471_065_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	066	0	1	01	01	H5471_066_0	10		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	066	0	1	01	01	H5471_066_0	10		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	066	0	1	01	01	H5471_066_0	10		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	066	0	1	01	01	H5471_066_0	10		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	066	0	1	01	01	H5471_066_0	10		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	068	0	1	01	01	H5471_068_0	8			Preferred Generic	4	11	1	2	1	1	111		01			1	30	60	100				2	2							30		34	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	068	0	1	01	01	H5471_068_0	8			Preferred Generic	4	11	1	2	1	3	111		01			1	30	60	100				2	2							30		34	0.00	0.00	0.00																																					0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	068	0	1	01	01	H5471_068_0	8			Generic	4	11	1	2	2	1	111		01			1	30	60	90				2	2							30		34	5.00	10.00	15.00																																					5.00				5.00		0.17						0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00	10.00	15.00										5.00		5.00
H5471	068	0	1	01	01	H5471_068_0	8			Preferred Brand	4	11	1	1	3	1	111		01			1	30	60	90				2	2							30		34				85.48	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00										35.00		35.00
H5471	068	0	1	01	01	H5471_068_0	8			Non-Preferred Brand	4	11	1	1	4	1	010		01			1	30														30		34				88.59	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00												35.00		35.00
H5471	068	0	1	01	01	H5471_068_0	8			Specialty Tier	4	11	1	1	5	1	010		01			1	30														30		34					25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	069	0	1	01	01	H5471_069_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	069	0	1	01	01	H5471_069_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	069	0	1	01	01	H5471_069_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	069	0	1	01	01	H5471_069_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	069	0	1	01	01	H5471_069_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	069	0	1	01	01	H5471_069_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	069	0	1	01	01	H5471_069_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	10.00																					10.00																		10.00				10.00		0.33			0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00						10.00						10.00		10.00
H5471	069	0	1	01	01	H5471_069_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	070	0	1	01	01	H5471_070_0	10			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	070	0	1	01	01	H5471_070_0	10			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	070	0	1	01	01	H5471_070_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	070	0	1	01	01	H5471_070_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	070	0	1	01	01	H5471_070_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	070	0	1	01	01	H5471_070_0	10			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	070	0	1	01	01	H5471_070_0	10			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	40.00																					40.00																		40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	070	0	1	01	01	H5471_070_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	071	0	1	01	01	H5471_071_0	10			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	071	0	1	01	01	H5471_071_0	10			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	071	0	1	01	01	H5471_071_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	071	0	1	01	01	H5471_071_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	071	0	1	01	01	H5471_071_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			10.00	30.00	30.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H5471	071	0	1	01	01	H5471_071_0	10			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	55.00																					55.00																		55.00				55.00		1.83			1.83			1.62	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	071	0	1	01	01	H5471_071_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	072	0	1	01	01	H5471_072_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	072	0	1	01	01	H5471_072_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	072	0	1	01	01	H5471_072_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	072	0	1	01	01	H5471_072_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	072	0	1	01	01	H5471_072_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	073	0	1	01	01	H5471_073_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	073	0	1	01	01	H5471_073_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	073	0	1	01	01	H5471_073_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	073	0	1	01	01	H5471_073_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	073	0	1	01	01	H5471_073_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	25.00	50.00	75.00																			25.00	50.00	75.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													25.00	50.00	75.00				25.00	50.00	75.00				25.00		25.00
H5471	073	0	1	01	01	H5471_073_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	25.00	50.00	75.00																			25.00	50.00	75.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	073	0	1	01	01	H5471_073_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	073	0	1	01	01	H5471_073_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	074	0	1	01	01	H5471_074_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	074	0	1	01	01	H5471_074_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	074	0	1	01	01	H5471_074_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	074	0	1	01	01	H5471_074_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	074	0	1	01	01	H5471_074_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	25.00	50.00	75.00																			25.00	75.00	75.00																25.00				25.00		0.83			0.83			0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													25.00	50.00	75.00				25.00	50.00	75.00				25.00		25.00
H5471	074	0	1	01	01	H5471_074_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	074	0	1	01	01	H5471_074_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	075	0	1	01	01	H5471_075_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	075	0	1	01	01	H5471_075_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	075	0	1	01	01	H5471_075_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	075	0	1	01	01	H5471_075_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	075	0	1	01	01	H5471_075_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	30.00	60.00	90.00																			30.00	60.00	90.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													30.00	60.00	90.00				30.00	60.00	90.00				30.00		30.00
H5471	075	0	1	01	01	H5471_075_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	30.00	60.00	90.00																			30.00	60.00	90.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	075	0	1	01	01	H5471_075_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	075	0	1	01	01	H5471_075_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	076	0	1	01	01	H5471_076_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	076	0	1	01	01	H5471_076_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	076	0	1	01	01	H5471_076_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	076	0	1	01	01	H5471_076_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	076	0	1	01	01	H5471_076_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	077	0	1	01	01	H5471_077_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	077	0	1	01	01	H5471_077_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	077	0	1	01	01	H5471_077_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	077	0	1	01	01	H5471_077_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	077	0	1	01	01	H5471_077_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	45.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H5471	077	0	1	01	01	H5471_077_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	077	0	1	01	01	H5471_077_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	078	0	1	01	01	H5471_078_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	078	0	1	01	01	H5471_078_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	078	0	1	01	01	H5471_078_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	078	0	1	01	01	H5471_078_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	078	0	1	01	01	H5471_078_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	35.00	70.00	105.00																			35.00	105.00	105.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	078	0	1	01	01	H5471_078_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	078	0	1	01	01	H5471_078_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	080	0	1	01	01	H5471_080_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	080	0	1	01	01	H5471_080_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	080	0	1	01	01	H5471_080_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	080	0	1	01	01	H5471_080_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	080	0	1	01	01	H5471_080_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H5471	080	0	1	01	01	H5471_080_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	080	0	1	01	01	H5471_080_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	080	0	1	01	01	H5471_080_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	082	0	1	01	01	H5471_082_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	082	0	1	01	01	H5471_082_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	082	0	1	01	01	H5471_082_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	082	0	1	01	01	H5471_082_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	082	0	1	01	01	H5471_082_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	083	0	1	01	01	H5471_083_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	083	0	1	01	01	H5471_083_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	083	0	1	01	01	H5471_083_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	083	0	1	01	01	H5471_083_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	083	0	1	01	01	H5471_083_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	45.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H5471	083	0	1	01	01	H5471_083_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	083	0	1	01	01	H5471_083_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	084	0	1	01	01	H5471_084_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	084	0	1	01	01	H5471_084_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	084	0	1	01	01	H5471_084_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	084	0	1	01	01	H5471_084_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	084	0	1	01	01	H5471_084_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	085	0	1	01	01	H5471_085_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	085	0	1	01	01	H5471_085_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	085	0	1	01	01	H5471_085_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	085	0	1	01	01	H5471_085_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	085	0	1	01	01	H5471_085_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H5471	085	0	1	01	01	H5471_085_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	30.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	085	0	1	01	01	H5471_085_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	085	0	1	01	01	H5471_085_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	103	0	1	01	01	H5471_103_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	103	0	1	01	01	H5471_103_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	103	0	1	01	01	H5471_103_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	103	0	1	01	01	H5471_103_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	103	0	1	01	01	H5471_103_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	103	0	1	01	01	H5471_103_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	103	0	1	01	01	H5471_103_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	104	0	1	01	01	H5471_104_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	104	0	1	01	01	H5471_104_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	104	0	1	01	01	H5471_104_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H5471	104	0	1	01	01	H5471_104_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	104	0	1	01	01	H5471_104_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	104	0	1	01	01	H5471_104_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	104	0	1	01	01	H5471_104_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	105	0	1	01	01	H5471_105_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	105	0	1	01	01	H5471_105_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	105	0	1	01	01	H5471_105_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			0.00	0.00	0.00																15.00				15.00		0.50			0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00	30.00	45.00				0.00	0.00	0.00				15.00		15.00
H5471	105	0	1	01	01	H5471_105_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			0.00	0.00	0.00																15.00				15.00		0.50			0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	105	0	1	01	01	H5471_105_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	105	0	1	01	01	H5471_105_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	105	0	1	01	01	H5471_105_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	106	0	1	01	01	H5471_106_0	9			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	106	0	1	01	01	H5471_106_0	9			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	106	0	1	01	01	H5471_106_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	20.00	40.00	60.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00				0.00	0.00	0.00				20.00		20.00
H5471	106	0	1	01	01	H5471_106_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	20.00	40.00	60.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	106	0	1	01	01	H5471_106_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	106	0	1	01	01	H5471_106_0	9			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	106	0	1	01	01	H5471_106_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	107	0	1	01	01	H5471_107_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	107	0	1	01	01	H5471_107_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	107	0	1	01	01	H5471_107_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H5471	107	0	1	01	01	H5471_107_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	107	0	1	01	01	H5471_107_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	107	0	1	01	01	H5471_107_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	107	0	1	01	01	H5471_107_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	108	0	1	01	01	H5471_108_0	7			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	108	0	1	01	01	H5471_108_0	7			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	108	0	1	01	01	H5471_108_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	20.00	40.00	60.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00				0.00	0.00	0.00				20.00		20.00
H5471	108	0	1	01	01	H5471_108_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	20.00	40.00	60.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	108	0	1	01	01	H5471_108_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	108	0	1	01	01	H5471_108_0	7			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	108	0	1	01	01	H5471_108_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	110	0	1	01	01	H5471_110_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	110	0	1	01	01	H5471_110_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	110	0	1	01	01	H5471_110_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	110	0	1	01	01	H5471_110_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	110	0	1	01	01	H5471_110_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	35.00	70.00	105.00																			35.00	105.00	105.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	110	0	1	01	01	H5471_110_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	110	0	1	01	01	H5471_110_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	111	0	1	01	01	H5471_111_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	111	0	1	01	01	H5471_111_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	111	0	1	01	01	H5471_111_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	111	0	1	01	01	H5471_111_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	111	0	1	01	01	H5471_111_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	112	0	1	01	01	H5471_112_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	112	0	1	01	01	H5471_112_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	112	0	1	01	01	H5471_112_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H5471	112	0	1	01	01	H5471_112_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	112	0	1	01	01	H5471_112_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	112	0	1	01	01	H5471_112_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	112	0	1	01	01	H5471_112_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	113	0	1	01	01	H5471_113_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	113	0	1	01	01	H5471_113_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	113	0	1	01	01	H5471_113_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	113	0	1	01	01	H5471_113_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	113	0	1	01	01	H5471_113_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	113	0	1	01	01	H5471_113_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	113	0	1	01	01	H5471_113_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	114	0	1	01	01	H5471_114_0	9			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	114	0	1	01	01	H5471_114_0	9			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	114	0	1	01	01	H5471_114_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	114	0	1	01	01	H5471_114_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	114	0	1	01	01	H5471_114_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	114	0	1	01	01	H5471_114_0	9			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	5.00																					5.00																		5.00				5.00		0.17			0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													5.00						5.00						5.00		5.00
H5471	114	0	1	01	01	H5471_114_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	115	0	1	01	01	H5471_115_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	115	0	1	01	01	H5471_115_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	115	0	1	01	01	H5471_115_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	115	0	1	01	01	H5471_115_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	115	0	1	01	01	H5471_115_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	116	0	1	01	01	H5471_116_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	116	0	1	01	01	H5471_116_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	116	0	1	01	01	H5471_116_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	116	0	1	01	01	H5471_116_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	116	0	1	01	01	H5471_116_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	116	0	1	01	01	H5471_116_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	116	0	1	01	01	H5471_116_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	116	0	1	01	01	H5471_116_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	117	0	1	01	01	H5471_117_0	9			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	117	0	1	01	01	H5471_117_0	9			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	117	0	1	01	01	H5471_117_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	20.00	40.00	60.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00				0.00	0.00	0.00				20.00		20.00
H5471	117	0	1	01	01	H5471_117_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	20.00	40.00	60.00																			0.00	0.00	0.00																20.00				20.00		0.67			0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	117	0	1	01	01	H5471_117_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	117	0	1	01	01	H5471_117_0	9			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	117	0	1	01	01	H5471_117_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	118	0	1	01	01	H5471_118_0	10		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	118	0	1	01	01	H5471_118_0	10		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	118	0	1	01	01	H5471_118_0	10		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	118	0	1	01	01	H5471_118_0	10		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	118	0	1	01	01	H5471_118_0	10		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	119	0	1	01	01	H5471_119_0	9			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	119	0	1	01	01	H5471_119_0	9			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	119	0	1	01	01	H5471_119_0	9			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	119	0	1	01	01	H5471_119_0	9			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	119	0	1	01	01	H5471_119_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	119	0	1	01	01	H5471_119_0	9			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	119	0	1	01	01	H5471_119_0	9			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	119	0	1	01	01	H5471_119_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	120	0	1	01	01	H5471_120_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	120	0	1	01	01	H5471_120_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	120	0	1	01	01	H5471_120_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H5471	120	0	1	01	01	H5471_120_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	120	0	1	01	01	H5471_120_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	120	0	1	01	01	H5471_120_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	120	0	1	01	01	H5471_120_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	121	0	1	01	01	H5471_121_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	121	0	1	01	01	H5471_121_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	121	0	1	01	01	H5471_121_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	121	0	1	01	01	H5471_121_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	121	0	1	01	01	H5471_121_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	122	0	1	01	01	H5471_122_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	122	0	1	01	01	H5471_122_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	122	0	1	01	01	H5471_122_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	122	0	1	01	01	H5471_122_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	122	0	1	01	01	H5471_122_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	122	0	1	01	01	H5471_122_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	122	0	1	01	01	H5471_122_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	122	0	1	01	01	H5471_122_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	123	0	1	01	01	H5471_123_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	123	0	1	01	01	H5471_123_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	123	0	1	01	01	H5471_123_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H5471	123	0	1	01	01	H5471_123_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	123	0	1	01	01	H5471_123_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	123	0	1	01	01	H5471_123_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	123	0	1	01	01	H5471_123_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	124	0	1	01	01	H5471_124_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	124	0	1	01	01	H5471_124_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	124	0	1	01	01	H5471_124_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	124	0	1	01	01	H5471_124_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	124	0	1	01	01	H5471_124_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	15.00	30.00	45.00																			15.00	45.00	45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00	30.00	45.00				15.00	30.00	45.00				15.00		15.00
H5471	124	0	1	01	01	H5471_124_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	75.00																					75.00																		75.00				75.00		2.50			2.50			2.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	124	0	1	01	01	H5471_124_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	125	0	1	01	01	H5471_125_0	9		N	Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	125	0	1	01	01	H5471_125_0	9		N	Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00
H5471	125	0	1	01	01	H5471_125_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5471	125	0	1	01	01	H5471_125_0	9		N	Non-Preferred Brand	4	11	1	2	4	1		010	01	010		1				30					30						30		34								100.00							95.00							95.00																		100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5471	125	0	1	01	01	H5471_125_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	126	0	1	01	01	H5471_126_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5471	126	0	1	01	01	H5471_126_0	8			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H5471	126	0	1	01	01	H5471_126_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5471	126	0	1	01	01	H5471_126_0	8			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H5471	126	0	1	01	01	H5471_126_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5471	126	0	1	01	01	H5471_126_0	8			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										2	1																
H5471	126	0	1	01	01	H5471_126_0	8			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H5471	126	0	1	01	01	H5471_126_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H5472	001	0	1	02	01	H5472_001_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	001	0	1	02	01	H5472_001_0	15			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5472	001	0	1	02	01	H5472_001_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	001	0	1	02	01	H5472_001_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5472	001	0	1	02	01	H5472_001_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5472	001	0	1	02	01	H5472_001_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				761.13	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5472	001	0	1	02	01	H5472_001_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5472	001	0	1	02	01	H5472_001_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5472	002	0	1	02	01	H5472_002_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	002	0	1	02	01	H5472_002_0	14			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5472	002	0	1	02	01	H5472_002_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	002	0	1	02	01	H5472_002_0	14			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5472	002	0	1	02	01	H5472_002_0	14			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5472	002	0	1	02	01	H5472_002_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				761.10	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5472	002	0	1	02	01	H5472_002_0	14			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5472	002	0	1	02	01	H5472_002_0	14			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5472	003	0	1	02	01	H5472_003_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	003	0	1	02	01	H5472_003_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5472	003	0	1	02	01	H5472_003_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5472	003	0	1	02	01	H5472_003_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5472	003	0	1	02	01	H5472_003_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5472	003	0	1	02	01	H5472_003_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				511.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5472	003	0	1	02	01	H5472_003_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5472	003	0	1	02	01	H5472_003_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5475	011	0	1	02	01	H5475_011_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	011	0	1	02	01	H5475_011_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	011	0	1	02	01	H5475_011_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5475	011	0	1	02	01	H5475_011_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.05	50	50	50				92.05	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	011	0	1	02	01	H5475_011_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H5475	011	0	1	02	01	H5475_011_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	022	0	1	02	01	H5475_022_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	022	0	1	02	01	H5475_022_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	022	0	1	02	01	H5475_022_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5475	022	0	1	02	01	H5475_022_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.85	47	47	47				99.85	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	022	0	1	02	01	H5475_022_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5475	022	0	1	02	01	H5475_022_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	024	0	1	02	01	H5475_024_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	024	0	1	02	01	H5475_024_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	024	0	1	02	01	H5475_024_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5475	024	0	1	02	01	H5475_024_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.57	50	50	50				77.57	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	024	0	1	02	01	H5475_024_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5475	024	0	1	02	01	H5475_024_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	026	0	1	02	01	H5475_026_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	026	0	1	02	01	H5475_026_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	026	0	1	02	01	H5475_026_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5475	026	0	1	02	01	H5475_026_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											73.98	50	50	50				73.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	026	0	1	02	01	H5475_026_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5475	026	0	1	02	01	H5475_026_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	031	0	1	01	01	H5475_031_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	031	0	1	01	01	H5475_031_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	031	0	1	01	01	H5475_031_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5475	031	0	1	01	01	H5475_031_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.39	50	50	50				92.39	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	031	0	1	01	01	H5475_031_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5475	031	0	1	01	01	H5475_031_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	032	0	1	01	01	H5475_032_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00											1.00	2.00	3.00				0.00	0.00	0.00				1.00				1.00			0.03	0.00		0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	032	0	1	01	01	H5475_032_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	032	0	1	01	01	H5475_032_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5475	032	0	1	01	01	H5475_032_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.82	50	50	50				91.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	032	0	1	01	01	H5475_032_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5475	032	0	1	01	01	H5475_032_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	038	0	1	01	01	H5475_038_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	038	0	1	01	01	H5475_038_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5475	038	0	1	01	01	H5475_038_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H5475	038	0	1	01	01	H5475_038_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											95.98	50	50	50				95.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5475	038	0	1	01	01	H5475_038_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5475	038	0	1	01	01	H5475_038_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5496	005	0	1	01	01	H5496_005_0	5			Preferred Generic	4	11	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5496	005	0	1	01	01	H5496_005_0	5			Preferred Generic	4	11	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5496	005	0	1	01	01	H5496_005_0	5			Generic	4	11	3	2	2	1	110		01	100		1	30		100				1	2			100				30		31	5.00		12.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5496	005	0	1	01	01	H5496_005_0	5			Generic	4	11	3	2	2	3	110		01	100		1	30		100				1	2			100				30		31	5.00		12.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5496	005	0	1	01	01	H5496_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	45.00		110.00																					90.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H5496	005	0	1	01	01	H5496_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	90.00		225.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5496	005	0	1	01	01	H5496_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				966.50	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5496	005	0	1	01	01	H5496_005_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	3.00		6.00																					0.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5496	007	0	1	01	01	H5496_007_0	6			Preferred Generic	4	11	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	007	0	1	01	01	H5496_007_0	6			Preferred Generic	4	11	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5496	007	0	1	01	01	H5496_007_0	6			Generic	4	11	3	2	2	1	110		01	100		1	30		100				1	2			100				30		31	5.00		12.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	007	0	1	01	01	H5496_007_0	6			Generic	4	11	3	2	2	3	110		01	100		1	30		100				1	2			100				30		31	5.00		12.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5496	007	0	1	01	01	H5496_007_0	6			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	45.00		110.00																					90.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H5496	007	0	1	01	01	H5496_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	90.00		225.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	007	0	1	01	01	H5496_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1509.61	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	011	0	1	01	01	H5496_011_0	7		N	Preferred Generic	4	11	1	1	1	1	110		01	100		1	30		100				1	2			100				30		31				0.00	0		0																				0															0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	011	0	1	01	01	H5496_011_0	7		N	Preferred Generic	4	11	1	1	1	3	110		01	100		1	30		100				1	2			100				30		31				0.00	0		0																				0															0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5496	011	0	1	01	01	H5496_011_0	7		N	Generic	4	11	3	1	2	1	110		01	100		1	30		100				1	2			100				30		31				0.00	0		0																				0															0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	011	0	1	01	01	H5496_011_0	7		N	Generic	4	11	3	1	2	3	110		01	100		1	30		100				1	2			100				30		31				0.00	0		0																				0															0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5496	011	0	1	01	01	H5496_011_0	7		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				102.12	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5496	011	0	1	01	01	H5496_011_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				110.55	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	011	0	1	01	01	H5496_011_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				854.24	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	012	0	1	01	01	H5496_012_0	7			Preferred Generic	4	11	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	012	0	1	01	01	H5496_012_0	7			Preferred Generic	4	11	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5496	012	0	1	01	01	H5496_012_0	7			Generic	4	11	3	2	2	1	110		01	100		1	30		100				1	2			100				30		31	3.00		6.00																					5.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	012	0	1	01	01	H5496_012_0	7			Generic	4	11	3	2	2	3	110		01	100		1	30		100				1	2			100				30		31	3.00		6.00																					5.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5496	012	0	1	01	01	H5496_012_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	30.00		90.00																					75.00																30.00				30.00		1.00						0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H5496	012	0	1	01	01	H5496_012_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	75.00		200.00																					180.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5496	012	0	1	01	01	H5496_012_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1306.14	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	013	0	1	04	01	H5521_013_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	013	0	1	04	01	H5521_013_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	013	0	1	04	01	H5521_013_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	013	0	1	04	01	H5521_013_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	013	0	1	04	01	H5521_013_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	013	0	1	04	01	H5521_013_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	013	0	1	04	01	H5521_013_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											990.73	33						680.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	015	0	1	04	01	H5521_015_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	015	0	1	04	01	H5521_015_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	015	0	1	04	01	H5521_015_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	015	0	1	04	01	H5521_015_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	015	0	1	04	01	H5521_015_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	015	0	1	04	01	H5521_015_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	015	0	1	04	01	H5521_015_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											631.07	28						456.26	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	016	0	1	04	01	H5521_016_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	016	0	1	04	01	H5521_016_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	016	0	1	04	01	H5521_016_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	016	0	1	04	01	H5521_016_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	016	0	1	04	01	H5521_016_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	016	0	1	04	01	H5521_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	016	0	1	04	01	H5521_016_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											840.82	33						655.75	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	020	0	1	04	01	H5521_020_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	020	0	1	04	01	H5521_020_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5521	020	0	1	04	01	H5521_020_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	020	0	1	04	01	H5521_020_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5521	020	0	1	04	01	H5521_020_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	020	0	1	04	01	H5521_020_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	020	0	1	04	01	H5521_020_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1205.63	33						670.30	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	022	0	1	04	01	H5521_022_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	022	0	1	04	01	H5521_022_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	022	0	1	04	01	H5521_022_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	022	0	1	04	01	H5521_022_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	022	0	1	04	01	H5521_022_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	022	0	1	04	01	H5521_022_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	022	0	1	04	01	H5521_022_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											878.98	33						546.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	027	0	1	04	01	H5521_027_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	027	0	1	04	01	H5521_027_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	027	0	1	04	01	H5521_027_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	027	0	1	04	01	H5521_027_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	027	0	1	04	01	H5521_027_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	027	0	1	04	01	H5521_027_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	027	0	1	04	01	H5521_027_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											696.89	28						484.48	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	033	0	1	04	01	H5521_033_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	033	0	1	04	01	H5521_033_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	033	0	1	04	01	H5521_033_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	033	0	1	04	01	H5521_033_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	033	0	1	04	01	H5521_033_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	033	0	1	04	01	H5521_033_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	033	0	1	04	01	H5521_033_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											879.95	28						631.79	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	037	0	1	04	01	H5521_037_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	037	0	1	04	01	H5521_037_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	037	0	1	04	01	H5521_037_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	037	0	1	04	01	H5521_037_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	037	0	1	04	01	H5521_037_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	037	0	1	04	01	H5521_037_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	037	0	1	04	01	H5521_037_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											750.85	30						726.68	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	040	0	1	04	01	H5521_040_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	040	0	1	04	01	H5521_040_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	040	0	1	04	01	H5521_040_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	040	0	1	04	01	H5521_040_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	040	0	1	04	01	H5521_040_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	040	0	1	04	01	H5521_040_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	040	0	1	04	01	H5521_040_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											960.64	30						722.11	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	053	0	1	04	01	H5521_053_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	053	0	1	04	01	H5521_053_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	053	0	1	04	01	H5521_053_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	053	0	1	04	01	H5521_053_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	053	0	1	04	01	H5521_053_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	053	0	1	04	01	H5521_053_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	053	0	1	04	01	H5521_053_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											629.66	33						448.14	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	055	0	1	04	01	H5521_055_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	055	0	1	04	01	H5521_055_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	055	0	1	04	01	H5521_055_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	055	0	1	04	01	H5521_055_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	055	0	1	04	01	H5521_055_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	055	0	1	04	01	H5521_055_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	055	0	1	04	01	H5521_055_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											951.65	33						734.87	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	056	0	1	04	01	H5521_056_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	056	0	1	04	01	H5521_056_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	056	0	1	04	01	H5521_056_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	056	0	1	04	01	H5521_056_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	056	0	1	04	01	H5521_056_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	056	0	1	04	01	H5521_056_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	056	0	1	04	01	H5521_056_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											984.09	33						578.32	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	076	0	1	04	01	H5521_076_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	076	0	1	04	01	H5521_076_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	076	0	1	04	01	H5521_076_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	076	0	1	04	01	H5521_076_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	076	0	1	04	01	H5521_076_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	076	0	1	04	01	H5521_076_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	076	0	1	04	01	H5521_076_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											909.44	30						678.16	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	077	0	1	04	01	H5521_077_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	077	0	1	04	01	H5521_077_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	077	0	1	04	01	H5521_077_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	077	0	1	04	01	H5521_077_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	077	0	1	04	01	H5521_077_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	077	0	1	04	01	H5521_077_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	077	0	1	04	01	H5521_077_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											923.08	30						592.75	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	081	0	1	04	01	H5521_081_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	081	0	1	04	01	H5521_081_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	081	0	1	04	01	H5521_081_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	081	0	1	04	01	H5521_081_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	081	0	1	04	01	H5521_081_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	081	0	1	04	01	H5521_081_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	081	0	1	04	01	H5521_081_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											896.93	30						612.28	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	084	0	1	04	01	H5521_084_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	084	0	1	04	01	H5521_084_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	084	0	1	04	01	H5521_084_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	084	0	1	04	01	H5521_084_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	084	0	1	04	01	H5521_084_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	084	0	1	04	01	H5521_084_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	084	0	1	04	01	H5521_084_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.75	28						546.86	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	085	0	1	04	01	H5521_085_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	085	0	1	04	01	H5521_085_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	085	0	1	04	01	H5521_085_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	085	0	1	04	01	H5521_085_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	085	0	1	04	01	H5521_085_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.85	25	25	25				51.69	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	085	0	1	04	01	H5521_085_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.23	50	50	50				73.26	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	085	0	1	04	01	H5521_085_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											878.43	33						634.13	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	086	0	1	04	01	H5521_086_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	086	0	1	04	01	H5521_086_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	086	0	1	04	01	H5521_086_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	086	0	1	04	01	H5521_086_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	086	0	1	04	01	H5521_086_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	086	0	1	04	01	H5521_086_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	086	0	1	04	01	H5521_086_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.84	33						622.77	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	087	0	1	04	01	H5521_087_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	087	0	1	04	01	H5521_087_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	087	0	1	04	01	H5521_087_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	087	0	1	04	01	H5521_087_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	087	0	1	04	01	H5521_087_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	087	0	1	04	01	H5521_087_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	087	0	1	04	01	H5521_087_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											687.42	33						562.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	088	0	1	04	01	H5521_088_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	088	0	1	04	01	H5521_088_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	088	0	1	04	01	H5521_088_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	088	0	1	04	01	H5521_088_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	088	0	1	04	01	H5521_088_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	088	0	1	04	01	H5521_088_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	088	0	1	04	01	H5521_088_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											825.53	33						605.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	089	0	1	04	01	H5521_089_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	089	0	1	04	01	H5521_089_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	089	0	1	04	01	H5521_089_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	089	0	1	04	01	H5521_089_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	089	0	1	04	01	H5521_089_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	089	0	1	04	01	H5521_089_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	089	0	1	04	01	H5521_089_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											915.57	33						639.64	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	090	0	1	04	01	H5521_090_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	090	0	1	04	01	H5521_090_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	090	0	1	04	01	H5521_090_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	090	0	1	04	01	H5521_090_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	090	0	1	04	01	H5521_090_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	090	0	1	04	01	H5521_090_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	090	0	1	04	01	H5521_090_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											949.04	33						540.98	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	091	0	1	04	01	H5521_091_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	091	0	1	04	01	H5521_091_0	4			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	091	0	1	04	01	H5521_091_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	091	0	1	04	01	H5521_091_0	4			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	091	0	1	04	01	H5521_091_0	4			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	091	0	1	04	01	H5521_091_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	091	0	1	04	01	H5521_091_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1103.12	33						697.44	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	095	0	1	04	01	H5521_095_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	095	0	1	04	01	H5521_095_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	095	0	1	04	01	H5521_095_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	095	0	1	04	01	H5521_095_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	095	0	1	04	01	H5521_095_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											102.76	25	25	25				93.37	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	095	0	1	04	01	H5521_095_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.65	50	50	50				47.77	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	095	0	1	04	01	H5521_095_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											708.30	29						484.05	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	099	0	1	04	01	H5521_099_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	099	0	1	04	01	H5521_099_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	099	0	1	04	01	H5521_099_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	099	0	1	04	01	H5521_099_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	099	0	1	04	01	H5521_099_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	099	0	1	04	01	H5521_099_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	099	0	1	04	01	H5521_099_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											767.48	33						569.20	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	100	0	1	04	01	H5521_100_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	100	0	1	04	01	H5521_100_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	100	0	1	04	01	H5521_100_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	100	0	1	04	01	H5521_100_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	100	0	1	04	01	H5521_100_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	100	0	1	04	01	H5521_100_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	100	0	1	04	01	H5521_100_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											866.52	33						586.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	101	0	1	04	01	H5521_101_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	101	0	1	04	01	H5521_101_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	101	0	1	04	01	H5521_101_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	101	0	1	04	01	H5521_101_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	101	0	1	04	01	H5521_101_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.54	25	25	25				76.54	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	101	0	1	04	01	H5521_101_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.25	50	50	50				25.47	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	101	0	1	04	01	H5521_101_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											920.32	33						686.51	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	110	0	1	04	01	H5521_110_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	110	0	1	04	01	H5521_110_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	110	0	1	04	01	H5521_110_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	110	0	1	04	01	H5521_110_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	110	0	1	04	01	H5521_110_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	110	0	1	04	01	H5521_110_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	110	0	1	04	01	H5521_110_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											764.78	30						665.05	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	116	0	1	04	01	H5521_116_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	116	0	1	04	01	H5521_116_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	116	0	1	04	01	H5521_116_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	116	0	1	04	01	H5521_116_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	116	0	1	04	01	H5521_116_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	116	0	1	04	01	H5521_116_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	116	0	1	04	01	H5521_116_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.13	33						654.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	117	0	1	04	01	H5521_117_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	117	0	1	04	01	H5521_117_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	117	0	1	04	01	H5521_117_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	117	0	1	04	01	H5521_117_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	117	0	1	04	01	H5521_117_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	117	0	1	04	01	H5521_117_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	117	0	1	04	01	H5521_117_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											715.90	28						483.01	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	118	0	1	04	01	H5521_118_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	118	0	1	04	01	H5521_118_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	118	0	1	04	01	H5521_118_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	118	0	1	04	01	H5521_118_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	118	0	1	04	01	H5521_118_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	118	0	1	04	01	H5521_118_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	118	0	1	04	01	H5521_118_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											922.67	28						519.47	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	119	0	1	04	01	H5521_119_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	119	0	1	04	01	H5521_119_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	119	0	1	04	01	H5521_119_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	119	0	1	04	01	H5521_119_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	119	0	1	04	01	H5521_119_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.41	25	25	25				50.00	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	119	0	1	04	01	H5521_119_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.37	50	50	50				71.87	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	119	0	1	04	01	H5521_119_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.05	33						576.70	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	120	0	1	04	01	H5521_120_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	120	0	1	04	01	H5521_120_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	120	0	1	04	01	H5521_120_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	120	0	1	04	01	H5521_120_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	120	0	1	04	01	H5521_120_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	120	0	1	04	01	H5521_120_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	120	0	1	04	01	H5521_120_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											694.11	28						611.86	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	121	0	1	04	01	H5521_121_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	121	0	1	04	01	H5521_121_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	121	0	1	04	01	H5521_121_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	121	0	1	04	01	H5521_121_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	121	0	1	04	01	H5521_121_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	121	0	1	04	01	H5521_121_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	121	0	1	04	01	H5521_121_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											686.20	30						462.29	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	122	0	1	04	01	H5521_122_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	122	0	1	04	01	H5521_122_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	122	0	1	04	01	H5521_122_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	122	0	1	04	01	H5521_122_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	122	0	1	04	01	H5521_122_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.11	25	25	25				90.47	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	122	0	1	04	01	H5521_122_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.86	50	50	50				65.38	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	122	0	1	04	01	H5521_122_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											901.25	29						601.08	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	123	0	1	04	01	H5521_123_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	123	0	1	04	01	H5521_123_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	123	0	1	04	01	H5521_123_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	123	0	1	04	01	H5521_123_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	123	0	1	04	01	H5521_123_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	123	0	1	04	01	H5521_123_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	123	0	1	04	01	H5521_123_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											759.35	30						566.71	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	124	0	1	04	01	H5521_124_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	124	0	1	04	01	H5521_124_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	124	0	1	04	01	H5521_124_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	124	0	1	04	01	H5521_124_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	124	0	1	04	01	H5521_124_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	124	0	1	04	01	H5521_124_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	124	0	1	04	01	H5521_124_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											844.50	30						604.27	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	125	0	1	04	01	H5521_125_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	125	0	1	04	01	H5521_125_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	125	0	1	04	01	H5521_125_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	125	0	1	04	01	H5521_125_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	125	0	1	04	01	H5521_125_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	125	0	1	04	01	H5521_125_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	125	0	1	04	01	H5521_125_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1026.52	33						749.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	127	0	1	04	01	H5521_127_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	127	0	1	04	01	H5521_127_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	127	0	1	04	01	H5521_127_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	127	0	1	04	01	H5521_127_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	127	0	1	04	01	H5521_127_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	127	0	1	04	01	H5521_127_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	127	0	1	04	01	H5521_127_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											789.74	30						542.13	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	128	0	1	04	01	H5521_128_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	128	0	1	04	01	H5521_128_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	128	0	1	04	01	H5521_128_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	128	0	1	04	01	H5521_128_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	128	0	1	04	01	H5521_128_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	128	0	1	04	01	H5521_128_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	128	0	1	04	01	H5521_128_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											811.78	30						746.38	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	134	0	1	04	01	H5521_134_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	134	0	1	04	01	H5521_134_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5521	134	0	1	04	01	H5521_134_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	134	0	1	04	01	H5521_134_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5521	134	0	1	04	01	H5521_134_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	134	0	1	04	01	H5521_134_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	134	0	1	04	01	H5521_134_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											983.37	33						562.95	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	139	0	1	04	01	H5521_139_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	139	0	1	04	01	H5521_139_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	139	0	1	04	01	H5521_139_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	139	0	1	04	01	H5521_139_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	139	0	1	04	01	H5521_139_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	139	0	1	04	01	H5521_139_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	139	0	1	04	01	H5521_139_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											856.59	30						710.30	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	140	0	1	04	01	H5521_140_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	140	0	1	04	01	H5521_140_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	140	0	1	04	01	H5521_140_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	140	0	1	04	01	H5521_140_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	140	0	1	04	01	H5521_140_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	140	0	1	04	01	H5521_140_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	140	0	1	04	01	H5521_140_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											998.92	30						596.93	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	141	0	1	04	01	H5521_141_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	141	0	1	04	01	H5521_141_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	141	0	1	04	01	H5521_141_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	141	0	1	04	01	H5521_141_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	141	0	1	04	01	H5521_141_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	141	0	1	04	01	H5521_141_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	141	0	1	04	01	H5521_141_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											970.56	33						817.58	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	144	0	1	04	01	H5521_144_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	144	0	1	04	01	H5521_144_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	144	0	1	04	01	H5521_144_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	144	0	1	04	01	H5521_144_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	144	0	1	04	01	H5521_144_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.56	25	25	25				73.32	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	144	0	1	04	01	H5521_144_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.29	40	40	40				78.80	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	144	0	1	04	01	H5521_144_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											802.01	29						589.52	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	150	0	1	04	01	H5521_150_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	150	0	1	04	01	H5521_150_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	150	0	1	04	01	H5521_150_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	150	0	1	04	01	H5521_150_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	150	0	1	04	01	H5521_150_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	150	0	1	04	01	H5521_150_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	150	0	1	04	01	H5521_150_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											740.53	30						589.19	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	154	0	1	04	01	H5521_154_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	154	0	1	04	01	H5521_154_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	154	0	1	04	01	H5521_154_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	154	0	1	04	01	H5521_154_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	154	0	1	04	01	H5521_154_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	154	0	1	04	01	H5521_154_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	154	0	1	04	01	H5521_154_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											870.02	33						640.93	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	156	0	1	04	01	H5521_156_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	156	0	1	04	01	H5521_156_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	156	0	1	04	01	H5521_156_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	156	0	1	04	01	H5521_156_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	156	0	1	04	01	H5521_156_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	156	0	1	04	01	H5521_156_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	156	0	1	04	01	H5521_156_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											783.27	33						679.99	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	157	0	1	04	01	H5521_157_0	10			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	157	0	1	04	01	H5521_157_0	10			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	157	0	1	04	01	H5521_157_0	10			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	157	0	1	04	01	H5521_157_0	10			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	157	0	1	04	01	H5521_157_0	10			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	157	0	1	04	01	H5521_157_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	157	0	1	04	01	H5521_157_0	10			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											911.40	33						779.42	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	159	0	1	04	01	H5521_159_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	159	0	1	04	01	H5521_159_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	159	0	1	04	01	H5521_159_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	159	0	1	04	01	H5521_159_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	159	0	1	04	01	H5521_159_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	159	0	1	04	01	H5521_159_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	159	0	1	04	01	H5521_159_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											741.90	33						688.13	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	160	0	1	04	01	H5521_160_0	10			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	160	0	1	04	01	H5521_160_0	10			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	160	0	1	04	01	H5521_160_0	10			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	160	0	1	04	01	H5521_160_0	10			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	160	0	1	04	01	H5521_160_0	10			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	160	0	1	04	01	H5521_160_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	160	0	1	04	01	H5521_160_0	10			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.11	33						645.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	168	0	1	04	01	H5521_168_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	168	0	1	04	01	H5521_168_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	168	0	1	04	01	H5521_168_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	168	0	1	04	01	H5521_168_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	168	0	1	04	01	H5521_168_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	168	0	1	04	01	H5521_168_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	168	0	1	04	01	H5521_168_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											778.81	30						533.54	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	169	0	1	04	01	H5521_169_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	169	0	1	04	01	H5521_169_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	169	0	1	04	01	H5521_169_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	169	0	1	04	01	H5521_169_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	169	0	1	04	01	H5521_169_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	169	0	1	04	01	H5521_169_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	169	0	1	04	01	H5521_169_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											714.04	30						637.49	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	170	0	1	04	01	H5521_170_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	170	0	1	04	01	H5521_170_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	170	0	1	04	01	H5521_170_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	170	0	1	04	01	H5521_170_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	170	0	1	04	01	H5521_170_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	170	0	1	04	01	H5521_170_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	170	0	1	04	01	H5521_170_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											975.97	33						653.39	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	171	0	1	04	01	H5521_171_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	171	0	1	04	01	H5521_171_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	171	0	1	04	01	H5521_171_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	171	0	1	04	01	H5521_171_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	171	0	1	04	01	H5521_171_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	171	0	1	04	01	H5521_171_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	171	0	1	04	01	H5521_171_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											763.64	33						609.76	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	178	0	1	04	01	H5521_178_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	178	0	1	04	01	H5521_178_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	178	0	1	04	01	H5521_178_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	178	0	1	04	01	H5521_178_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	178	0	1	04	01	H5521_178_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	178	0	1	04	01	H5521_178_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	178	0	1	04	01	H5521_178_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.32	33						577.14	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	184	0	1	04	01	H5521_184_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	184	0	1	04	01	H5521_184_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	184	0	1	04	01	H5521_184_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	184	0	1	04	01	H5521_184_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	184	0	1	04	01	H5521_184_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.14	25	25	25				75.65	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	184	0	1	04	01	H5521_184_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.18	50	50	50				33.35	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	184	0	1	04	01	H5521_184_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.91	33						574.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	190	0	1	04	01	H5521_190_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	190	0	1	04	01	H5521_190_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	190	0	1	04	01	H5521_190_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	190	0	1	04	01	H5521_190_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	190	0	1	04	01	H5521_190_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	190	0	1	04	01	H5521_190_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	190	0	1	04	01	H5521_190_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1031.97	33						657.22	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	194	0	1	04	01	H5521_194_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	194	0	1	04	01	H5521_194_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	194	0	1	04	01	H5521_194_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	194	0	1	04	01	H5521_194_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	194	0	1	04	01	H5521_194_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	194	0	1	04	01	H5521_194_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	194	0	1	04	01	H5521_194_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											717.39	33						663.70	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	195	0	1	04	01	H5521_195_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	195	0	1	04	01	H5521_195_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	195	0	1	04	01	H5521_195_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	195	0	1	04	01	H5521_195_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	195	0	1	04	01	H5521_195_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	195	0	1	04	01	H5521_195_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	195	0	1	04	01	H5521_195_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											703.42	30						446.87	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	197	0	1	04	01	H5521_197_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	197	0	1	04	01	H5521_197_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	197	0	1	04	01	H5521_197_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	197	0	1	04	01	H5521_197_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	197	0	1	04	01	H5521_197_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.87	25	25	25				79.74	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	197	0	1	04	01	H5521_197_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.10	50	50	50				25.52	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	197	0	1	04	01	H5521_197_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											927.06	33						674.76	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	207	0	1	04	01	H5521_207_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	207	0	1	04	01	H5521_207_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	207	0	1	04	01	H5521_207_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	207	0	1	04	01	H5521_207_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	207	0	1	04	01	H5521_207_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.93	25	25	25				48.67	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	207	0	1	04	01	H5521_207_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.22	50	50	50				61.50	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	207	0	1	04	01	H5521_207_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											853.35	33						600.53	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	211	0	1	04	01	H5521_211_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	211	0	1	04	01	H5521_211_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	211	0	1	04	01	H5521_211_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	211	0	1	04	01	H5521_211_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	211	0	1	04	01	H5521_211_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	211	0	1	04	01	H5521_211_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	211	0	1	04	01	H5521_211_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1034.47	33						712.24	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	214	0	1	04	01	H5521_214_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	214	0	1	04	01	H5521_214_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	214	0	1	04	01	H5521_214_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	214	0	1	04	01	H5521_214_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	214	0	1	04	01	H5521_214_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	214	0	1	04	01	H5521_214_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	214	0	1	04	01	H5521_214_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											660.16	33						600.42	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	215	0	1	04	01	H5521_215_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	215	0	1	04	01	H5521_215_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	215	0	1	04	01	H5521_215_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	215	0	1	04	01	H5521_215_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	215	0	1	04	01	H5521_215_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	215	0	1	04	01	H5521_215_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	215	0	1	04	01	H5521_215_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											775.55	30						603.71	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	216	0	1	04	01	H5521_216_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	216	0	1	04	01	H5521_216_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	216	0	1	04	01	H5521_216_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	216	0	1	04	01	H5521_216_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	216	0	1	04	01	H5521_216_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	216	0	1	04	01	H5521_216_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	216	0	1	04	01	H5521_216_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.95	33						683.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	217	0	1	04	01	H5521_217_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	217	0	1	04	01	H5521_217_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	217	0	1	04	01	H5521_217_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	217	0	1	04	01	H5521_217_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	217	0	1	04	01	H5521_217_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	217	0	1	04	01	H5521_217_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	217	0	1	04	01	H5521_217_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											914.72	33						716.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	218	0	1	04	01	H5521_218_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	218	0	1	04	01	H5521_218_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	218	0	1	04	01	H5521_218_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	218	0	1	04	01	H5521_218_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	218	0	1	04	01	H5521_218_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	218	0	1	04	01	H5521_218_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	218	0	1	04	01	H5521_218_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											829.12	33						664.80	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	219	0	1	04	01	H5521_219_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	219	0	1	04	01	H5521_219_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	219	0	1	04	01	H5521_219_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	219	0	1	04	01	H5521_219_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	219	0	1	04	01	H5521_219_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	219	0	1	04	01	H5521_219_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	219	0	1	04	01	H5521_219_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											852.39	33						732.18	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	220	0	1	04	01	H5521_220_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	220	0	1	04	01	H5521_220_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	220	0	1	04	01	H5521_220_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	220	0	1	04	01	H5521_220_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	220	0	1	04	01	H5521_220_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	220	0	1	04	01	H5521_220_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	220	0	1	04	01	H5521_220_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											883.48	33						659.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	222	0	1	04	01	H5521_222_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	222	0	1	04	01	H5521_222_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	222	0	1	04	01	H5521_222_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	222	0	1	04	01	H5521_222_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	222	0	1	04	01	H5521_222_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	222	0	1	04	01	H5521_222_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	222	0	1	04	01	H5521_222_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.79	33						671.01	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	223	0	1	04	01	H5521_223_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	223	0	1	04	01	H5521_223_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	223	0	1	04	01	H5521_223_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	223	0	1	04	01	H5521_223_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	223	0	1	04	01	H5521_223_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	223	0	1	04	01	H5521_223_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	223	0	1	04	01	H5521_223_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.45	33						638.46	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	224	0	1	04	01	H5521_224_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	224	0	1	04	01	H5521_224_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	224	0	1	04	01	H5521_224_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	224	0	1	04	01	H5521_224_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	224	0	1	04	01	H5521_224_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	224	0	1	04	01	H5521_224_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	224	0	1	04	01	H5521_224_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.20	33						648.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	226	0	1	04	01	H5521_226_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	226	0	1	04	01	H5521_226_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	226	0	1	04	01	H5521_226_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	226	0	1	04	01	H5521_226_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	226	0	1	04	01	H5521_226_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	226	0	1	04	01	H5521_226_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	226	0	1	04	01	H5521_226_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											911.23	33						614.60	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	227	0	1	04	01	H5521_227_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	227	0	1	04	01	H5521_227_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	227	0	1	04	01	H5521_227_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	227	0	1	04	01	H5521_227_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	227	0	1	04	01	H5521_227_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	227	0	1	04	01	H5521_227_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	227	0	1	04	01	H5521_227_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											769.47	33						638.92	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	230	0	1	04	01	H5521_230_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	230	0	1	04	01	H5521_230_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	230	0	1	04	01	H5521_230_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	230	0	1	04	01	H5521_230_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	230	0	1	04	01	H5521_230_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	230	0	1	04	01	H5521_230_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	230	0	1	04	01	H5521_230_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											787.50	33						663.51	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	231	0	1	04	01	H5521_231_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	231	0	1	04	01	H5521_231_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	231	0	1	04	01	H5521_231_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	231	0	1	04	01	H5521_231_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	231	0	1	04	01	H5521_231_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	231	0	1	04	01	H5521_231_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	231	0	1	04	01	H5521_231_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											744.52	33						578.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	232	0	1	04	01	H5521_232_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	232	0	1	04	01	H5521_232_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	232	0	1	04	01	H5521_232_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	232	0	1	04	01	H5521_232_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	232	0	1	04	01	H5521_232_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	232	0	1	04	01	H5521_232_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	232	0	1	04	01	H5521_232_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											816.96	33						707.93	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	233	0	1	04	01	H5521_233_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	233	0	1	04	01	H5521_233_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	233	0	1	04	01	H5521_233_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	233	0	1	04	01	H5521_233_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	233	0	1	04	01	H5521_233_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	233	0	1	04	01	H5521_233_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	233	0	1	04	01	H5521_233_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											853.08	33						697.00	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	234	0	1	04	01	H5521_234_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	234	0	1	04	01	H5521_234_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	234	0	1	04	01	H5521_234_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	234	0	1	04	01	H5521_234_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	234	0	1	04	01	H5521_234_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	234	0	1	04	01	H5521_234_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	234	0	1	04	01	H5521_234_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											854.69	33						720.42	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	236	0	1	04	01	H5521_236_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	236	0	1	04	01	H5521_236_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	236	0	1	04	01	H5521_236_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	236	0	1	04	01	H5521_236_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	236	0	1	04	01	H5521_236_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	236	0	1	04	01	H5521_236_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	236	0	1	04	01	H5521_236_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											732.83	30						633.59	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	243	0	1	04	01	H5521_243_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	243	0	1	04	01	H5521_243_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	243	0	1	04	01	H5521_243_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	243	0	1	04	01	H5521_243_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	243	0	1	04	01	H5521_243_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	243	0	1	04	01	H5521_243_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	243	0	1	04	01	H5521_243_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											785.66	33						684.95	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	245	0	1	04	01	H5521_245_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	245	0	1	04	01	H5521_245_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	245	0	1	04	01	H5521_245_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	245	0	1	04	01	H5521_245_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	245	0	1	04	01	H5521_245_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	245	0	1	04	01	H5521_245_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	245	0	1	04	01	H5521_245_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1029.18	33						558.05	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	246	0	1	04	01	H5521_246_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	246	0	1	04	01	H5521_246_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	246	0	1	04	01	H5521_246_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	246	0	1	04	01	H5521_246_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	246	0	1	04	01	H5521_246_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.91	25	25	25				79.06	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	246	0	1	04	01	H5521_246_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.21	50	50	50				25.93	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	246	0	1	04	01	H5521_246_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											920.93	33						659.20	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	247	0	1	04	01	H5521_247_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	247	0	1	04	01	H5521_247_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	247	0	1	04	01	H5521_247_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	247	0	1	04	01	H5521_247_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	247	0	1	04	01	H5521_247_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	247	0	1	04	01	H5521_247_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	247	0	1	04	01	H5521_247_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											950.38	30						661.74	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	249	0	1	04	01	H5521_249_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	249	0	1	04	01	H5521_249_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	249	0	1	04	01	H5521_249_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	249	0	1	04	01	H5521_249_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	249	0	1	04	01	H5521_249_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	249	0	1	04	01	H5521_249_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	249	0	1	04	01	H5521_249_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											957.04	30						732.23	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	250	0	1	04	01	H5521_250_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	250	0	1	04	01	H5521_250_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	250	0	1	04	01	H5521_250_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	250	0	1	04	01	H5521_250_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	250	0	1	04	01	H5521_250_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.81	25	25	25				46.40	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	250	0	1	04	01	H5521_250_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.07	50	50	50				70.66	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	250	0	1	04	01	H5521_250_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											788.71	33						779.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	251	0	1	04	01	H5521_251_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	251	0	1	04	01	H5521_251_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	251	0	1	04	01	H5521_251_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	251	0	1	04	01	H5521_251_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	251	0	1	04	01	H5521_251_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	251	0	1	04	01	H5521_251_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	251	0	1	04	01	H5521_251_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.93	30						638.93	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	254	0	1	04	01	H5521_254_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	254	0	1	04	01	H5521_254_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	254	0	1	04	01	H5521_254_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	254	0	1	04	01	H5521_254_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	254	0	1	04	01	H5521_254_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	254	0	1	04	01	H5521_254_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	254	0	1	04	01	H5521_254_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											767.13	33						539.22	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	259	0	1	04	01	H5521_259_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	259	0	1	04	01	H5521_259_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	259	0	1	04	01	H5521_259_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	259	0	1	04	01	H5521_259_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	259	0	1	04	01	H5521_259_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	259	0	1	04	01	H5521_259_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	259	0	1	04	01	H5521_259_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											879.12	33						663.80	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	260	0	1	04	01	H5521_260_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	260	0	1	04	01	H5521_260_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	260	0	1	04	01	H5521_260_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	260	0	1	04	01	H5521_260_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	260	0	1	04	01	H5521_260_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	260	0	1	04	01	H5521_260_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	260	0	1	04	01	H5521_260_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.10	33						688.58	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	261	0	1	04	01	H5521_261_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	261	0	1	04	01	H5521_261_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	261	0	1	04	01	H5521_261_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	261	0	1	04	01	H5521_261_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	261	0	1	04	01	H5521_261_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.12	25	25	25				50.24	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	261	0	1	04	01	H5521_261_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.94	50	50	50				62.10	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	261	0	1	04	01	H5521_261_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											805.79	33						632.54	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	262	0	1	04	01	H5521_262_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	262	0	1	04	01	H5521_262_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	262	0	1	04	01	H5521_262_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	262	0	1	04	01	H5521_262_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	262	0	1	04	01	H5521_262_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.88	25	25	25				47.32	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	262	0	1	04	01	H5521_262_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.01	50	50	50				57.67	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	262	0	1	04	01	H5521_262_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											799.91	33						716.60	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	263	0	1	04	01	H5521_263_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	263	0	1	04	01	H5521_263_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	263	0	1	04	01	H5521_263_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	263	0	1	04	01	H5521_263_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	263	0	1	04	01	H5521_263_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.82	25	25	25				49.90	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	263	0	1	04	01	H5521_263_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.52	50	50	50				69.32	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	263	0	1	04	01	H5521_263_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1068.47	33						696.34	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	266	0	1	04	01	H5521_266_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	266	0	1	04	01	H5521_266_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	266	0	1	04	01	H5521_266_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	266	0	1	04	01	H5521_266_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	266	0	1	04	01	H5521_266_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	266	0	1	04	01	H5521_266_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	266	0	1	04	01	H5521_266_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											830.82	33						667.52	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	268	0	1	04	01	H5521_268_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	268	0	1	04	01	H5521_268_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	268	0	1	04	01	H5521_268_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	268	0	1	04	01	H5521_268_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	268	0	1	04	01	H5521_268_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	268	0	1	04	01	H5521_268_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	268	0	1	04	01	H5521_268_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1003.12	30						544.41	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	269	0	1	04	01	H5521_269_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	269	0	1	04	01	H5521_269_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	269	0	1	04	01	H5521_269_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	269	0	1	04	01	H5521_269_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	269	0	1	04	01	H5521_269_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	269	0	1	04	01	H5521_269_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	269	0	1	04	01	H5521_269_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.61	30						583.16	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	270	0	1	04	01	H5521_270_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	270	0	1	04	01	H5521_270_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	270	0	1	04	01	H5521_270_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	270	0	1	04	01	H5521_270_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	270	0	1	04	01	H5521_270_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	270	0	1	04	01	H5521_270_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	270	0	1	04	01	H5521_270_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1063.06	30						663.02	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	271	0	1	04	01	H5521_271_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	271	0	1	04	01	H5521_271_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	271	0	1	04	01	H5521_271_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	271	0	1	04	01	H5521_271_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	271	0	1	04	01	H5521_271_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	271	0	1	04	01	H5521_271_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	271	0	1	04	01	H5521_271_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											806.77	30						509.24	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	272	0	1	04	01	H5521_272_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	272	0	1	04	01	H5521_272_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	272	0	1	04	01	H5521_272_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	272	0	1	04	01	H5521_272_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	272	0	1	04	01	H5521_272_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	272	0	1	04	01	H5521_272_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	272	0	1	04	01	H5521_272_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											937.76	30						531.24	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	273	0	1	04	01	H5521_273_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	273	0	1	04	01	H5521_273_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	273	0	1	04	01	H5521_273_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	273	0	1	04	01	H5521_273_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	273	0	1	04	01	H5521_273_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	273	0	1	04	01	H5521_273_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	273	0	1	04	01	H5521_273_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											918.89	30						605.82	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	275	0	1	04	01	H5521_275_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	275	0	1	04	01	H5521_275_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	275	0	1	04	01	H5521_275_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	275	0	1	04	01	H5521_275_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	275	0	1	04	01	H5521_275_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	275	0	1	04	01	H5521_275_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	275	0	1	04	01	H5521_275_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											725.77	28						491.52	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	277	0	1	04	01	H5521_277_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	277	0	1	04	01	H5521_277_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	277	0	1	04	01	H5521_277_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	277	0	1	04	01	H5521_277_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	277	0	1	04	01	H5521_277_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	277	0	1	04	01	H5521_277_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	277	0	1	04	01	H5521_277_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											665.61	28						611.70	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	278	0	1	04	01	H5521_278_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	278	0	1	04	01	H5521_278_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	278	0	1	04	01	H5521_278_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	278	0	1	04	01	H5521_278_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	278	0	1	04	01	H5521_278_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											53.25	25	25	25				47.02	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	278	0	1	04	01	H5521_278_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.47	50	50	50				65.79	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	278	0	1	04	01	H5521_278_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											795.50	33						789.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	280	0	1	04	01	H5521_280_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	280	0	1	04	01	H5521_280_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	280	0	1	04	01	H5521_280_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	280	0	1	04	01	H5521_280_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	280	0	1	04	01	H5521_280_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	280	0	1	04	01	H5521_280_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	280	0	1	04	01	H5521_280_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											743.35	33						614.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	283	0	1	04	01	H5521_283_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	283	0	1	04	01	H5521_283_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5521	283	0	1	04	01	H5521_283_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	283	0	1	04	01	H5521_283_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5521	283	0	1	04	01	H5521_283_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	283	0	1	04	01	H5521_283_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	283	0	1	04	01	H5521_283_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											893.85	33						645.81	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	284	0	1	04	01	H5521_284_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	284	0	1	04	01	H5521_284_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	284	0	1	04	01	H5521_284_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	284	0	1	04	01	H5521_284_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	284	0	1	04	01	H5521_284_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	284	0	1	04	01	H5521_284_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	284	0	1	04	01	H5521_284_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											667.43	33						647.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	285	0	1	04	01	H5521_285_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	285	0	1	04	01	H5521_285_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	285	0	1	04	01	H5521_285_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	285	0	1	04	01	H5521_285_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	285	0	1	04	01	H5521_285_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	285	0	1	04	01	H5521_285_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	285	0	1	04	01	H5521_285_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											951.94	33						770.01	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	288	0	1	04	01	H5521_288_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	288	0	1	04	01	H5521_288_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	288	0	1	04	01	H5521_288_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	288	0	1	04	01	H5521_288_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	288	0	1	04	01	H5521_288_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	288	0	1	04	01	H5521_288_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	288	0	1	04	01	H5521_288_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											756.51	33						630.74	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	289	0	1	04	01	H5521_289_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	289	0	1	04	01	H5521_289_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	289	0	1	04	01	H5521_289_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	289	0	1	04	01	H5521_289_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	289	0	1	04	01	H5521_289_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	289	0	1	04	01	H5521_289_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	289	0	1	04	01	H5521_289_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											882.21	30						643.97	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	290	0	1	04	01	H5521_290_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	290	0	1	04	01	H5521_290_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	290	0	1	04	01	H5521_290_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	290	0	1	04	01	H5521_290_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	290	0	1	04	01	H5521_290_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	290	0	1	04	01	H5521_290_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	290	0	1	04	01	H5521_290_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											993.78	33						773.42	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	292	0	1	04	01	H5521_292_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	292	0	1	04	01	H5521_292_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	292	0	1	04	01	H5521_292_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	292	0	1	04	01	H5521_292_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	292	0	1	04	01	H5521_292_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	292	0	1	04	01	H5521_292_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	292	0	1	04	01	H5521_292_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											816.07	33						585.10	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	293	0	1	04	01	H5521_293_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	293	0	1	04	01	H5521_293_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	293	0	1	04	01	H5521_293_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	293	0	1	04	01	H5521_293_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	293	0	1	04	01	H5521_293_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	293	0	1	04	01	H5521_293_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	293	0	1	04	01	H5521_293_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											617.93	33						518.80	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	294	0	1	04	01	H5521_294_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	294	0	1	04	01	H5521_294_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	294	0	1	04	01	H5521_294_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	294	0	1	04	01	H5521_294_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	294	0	1	04	01	H5521_294_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.35	25	25	25				48.29	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	294	0	1	04	01	H5521_294_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.00	50	50	50				63.33	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	294	0	1	04	01	H5521_294_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											827.41	33						673.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	299	0	1	04	01	H5521_299_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	299	0	1	04	01	H5521_299_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	299	0	1	04	01	H5521_299_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	299	0	1	04	01	H5521_299_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	299	0	1	04	01	H5521_299_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.52	25	25	25				81.59	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	299	0	1	04	01	H5521_299_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.18	50	50	50				27.32	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	299	0	1	04	01	H5521_299_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											799.56	33						568.64	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	301	0	1	04	01	H5521_301_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	301	0	1	04	01	H5521_301_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	301	0	1	04	01	H5521_301_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	301	0	1	04	01	H5521_301_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	301	0	1	04	01	H5521_301_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	301	0	1	04	01	H5521_301_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	301	0	1	04	01	H5521_301_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											809.52	33						591.44	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	302	0	1	04	01	H5521_302_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	302	0	1	04	01	H5521_302_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	302	0	1	04	01	H5521_302_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	302	0	1	04	01	H5521_302_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	302	0	1	04	01	H5521_302_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.79	25	25	25				98.69	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	302	0	1	04	01	H5521_302_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.04	40	40	40				39.74	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	302	0	1	04	01	H5521_302_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											669.01	27						572.96	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	303	0	1	04	01	H5521_303_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	303	0	1	04	01	H5521_303_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	303	0	1	04	01	H5521_303_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	303	0	1	04	01	H5521_303_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	303	0	1	04	01	H5521_303_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.78	25	25	25				83.67	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	303	0	1	04	01	H5521_303_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.51	50	50	50				24.46	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	303	0	1	04	01	H5521_303_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											823.88	33						640.66	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	305	0	1	04	01	H5521_305_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	305	0	1	04	01	H5521_305_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	305	0	1	04	01	H5521_305_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	305	0	1	04	01	H5521_305_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	305	0	1	04	01	H5521_305_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	305	0	1	04	01	H5521_305_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	305	0	1	04	01	H5521_305_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.31	30						568.31	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	310	0	1	04	01	H5521_310_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	310	0	1	04	01	H5521_310_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	310	0	1	04	01	H5521_310_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	310	0	1	04	01	H5521_310_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	310	0	1	04	01	H5521_310_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.09	25	25	25				71.70	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	310	0	1	04	01	H5521_310_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.81	40	40	40				81.84	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	310	0	1	04	01	H5521_310_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											754.43	29						545.97	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	311	0	1	04	01	H5521_311_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	311	0	1	04	01	H5521_311_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	311	0	1	04	01	H5521_311_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	311	0	1	04	01	H5521_311_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	311	0	1	04	01	H5521_311_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	311	0	1	04	01	H5521_311_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	311	0	1	04	01	H5521_311_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											910.95	33						726.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	312	0	1	04	01	H5521_312_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	312	0	1	04	01	H5521_312_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	312	0	1	04	01	H5521_312_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	312	0	1	04	01	H5521_312_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	312	0	1	04	01	H5521_312_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.37	25	25	25				50.52	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	312	0	1	04	01	H5521_312_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.38	50	50	50				73.31	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	312	0	1	04	01	H5521_312_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											845.61	33						691.39	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	313	0	1	04	01	H5521_313_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	313	0	1	04	01	H5521_313_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	313	0	1	04	01	H5521_313_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	313	0	1	04	01	H5521_313_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	313	0	1	04	01	H5521_313_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											108.09	25	25	25				97.34	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	313	0	1	04	01	H5521_313_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.80	50	50	50				51.44	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	313	0	1	04	01	H5521_313_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											863.55	29						627.95	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	314	0	1	04	01	H5521_314_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	314	0	1	04	01	H5521_314_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	314	0	1	04	01	H5521_314_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	314	0	1	04	01	H5521_314_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	314	0	1	04	01	H5521_314_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	314	0	1	04	01	H5521_314_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	314	0	1	04	01	H5521_314_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											789.48	33						659.22	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	318	0	1	04	01	H5521_318_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	318	0	1	04	01	H5521_318_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	318	0	1	04	01	H5521_318_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	318	0	1	04	01	H5521_318_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	318	0	1	04	01	H5521_318_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.81	25	25	25				70.82	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	318	0	1	04	01	H5521_318_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.06	40	40	40				85.28	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	318	0	1	04	01	H5521_318_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											834.23	29						608.38	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	319	0	1	04	01	H5521_319_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	319	0	1	04	01	H5521_319_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	319	0	1	04	01	H5521_319_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	319	0	1	04	01	H5521_319_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	319	0	1	04	01	H5521_319_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	319	0	1	04	01	H5521_319_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	319	0	1	04	01	H5521_319_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1100.09	33						656.17	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	321	0	1	04	01	H5521_321_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	321	0	1	04	01	H5521_321_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	321	0	1	04	01	H5521_321_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	321	0	1	04	01	H5521_321_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	321	0	1	04	01	H5521_321_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	321	0	1	04	01	H5521_321_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	321	0	1	04	01	H5521_321_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											846.29	33						587.52	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	326	0	1	04	01	H5521_326_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	326	0	1	04	01	H5521_326_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	326	0	1	04	01	H5521_326_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	326	0	1	04	01	H5521_326_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	326	0	1	04	01	H5521_326_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	326	0	1	04	01	H5521_326_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	326	0	1	04	01	H5521_326_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											666.99	30						613.29	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	328	0	1	04	01	H5521_328_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	328	0	1	04	01	H5521_328_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	328	0	1	04	01	H5521_328_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	328	0	1	04	01	H5521_328_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	328	0	1	04	01	H5521_328_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	328	0	1	04	01	H5521_328_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	328	0	1	04	01	H5521_328_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											888.03	33						737.53	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	331	0	1	04	01	H5521_331_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	331	0	1	04	01	H5521_331_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	331	0	1	04	01	H5521_331_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	331	0	1	04	01	H5521_331_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	331	0	1	04	01	H5521_331_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	331	0	1	04	01	H5521_331_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	331	0	1	04	01	H5521_331_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											841.84	33						681.12	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	332	0	1	04	01	H5521_332_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	332	0	1	04	01	H5521_332_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	332	0	1	04	01	H5521_332_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	332	0	1	04	01	H5521_332_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	332	0	1	04	01	H5521_332_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	332	0	1	04	01	H5521_332_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	332	0	1	04	01	H5521_332_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											778.55	33						580.25	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	333	0	1	04	01	H5521_333_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	333	0	1	04	01	H5521_333_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	333	0	1	04	01	H5521_333_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	333	0	1	04	01	H5521_333_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	333	0	1	04	01	H5521_333_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	333	0	1	04	01	H5521_333_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	333	0	1	04	01	H5521_333_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											572.71	33						428.68	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	340	0	1	04	01	H5521_340_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	340	0	1	04	01	H5521_340_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	340	0	1	04	01	H5521_340_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	340	0	1	04	01	H5521_340_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	340	0	1	04	01	H5521_340_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.36	25	25	25				63.70	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	340	0	1	04	01	H5521_340_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.44	40	40	40				76.19	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	340	0	1	04	01	H5521_340_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											586.24	29						561.04	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	341	0	1	04	01	H5521_341_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	341	0	1	04	01	H5521_341_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	341	0	1	04	01	H5521_341_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	341	0	1	04	01	H5521_341_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	341	0	1	04	01	H5521_341_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	341	0	1	04	01	H5521_341_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	341	0	1	04	01	H5521_341_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											801.84	28						561.42	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	344	0	1	04	01	H5521_344_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	344	0	1	04	01	H5521_344_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	344	0	1	04	01	H5521_344_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	344	0	1	04	01	H5521_344_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	344	0	1	04	01	H5521_344_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	344	0	1	04	01	H5521_344_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	344	0	1	04	01	H5521_344_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											628.46	30						708.47	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	345	0	1	04	01	H5521_345_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	345	0	1	04	01	H5521_345_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	345	0	1	04	01	H5521_345_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	345	0	1	04	01	H5521_345_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	345	0	1	04	01	H5521_345_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.48	25	25	25				82.75	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	345	0	1	04	01	H5521_345_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.74	50	50	50				24.76	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	345	0	1	04	01	H5521_345_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											938.76	33						656.81	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	348	0	1	04	01	H5521_348_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	348	0	1	04	01	H5521_348_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	348	0	1	04	01	H5521_348_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	348	0	1	04	01	H5521_348_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	348	0	1	04	01	H5521_348_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	348	0	1	04	01	H5521_348_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	348	0	1	04	01	H5521_348_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											802.92	28						603.28	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	352	0	1	04	01	H5521_352_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	352	0	1	04	01	H5521_352_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	352	0	1	04	01	H5521_352_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	352	0	1	04	01	H5521_352_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	352	0	1	04	01	H5521_352_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	352	0	1	04	01	H5521_352_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	352	0	1	04	01	H5521_352_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.35	33						807.62	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	360	0	1	04	01	H5521_360_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	360	0	1	04	01	H5521_360_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	360	0	1	04	01	H5521_360_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	360	0	1	04	01	H5521_360_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	360	0	1	04	01	H5521_360_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	360	0	1	04	01	H5521_360_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	360	0	1	04	01	H5521_360_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											884.80	33						656.26	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	363	0	1	04	01	H5521_363_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	363	0	1	04	01	H5521_363_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	363	0	1	04	01	H5521_363_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	363	0	1	04	01	H5521_363_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	363	0	1	04	01	H5521_363_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	363	0	1	04	01	H5521_363_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	363	0	1	04	01	H5521_363_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											870.62	33						623.35	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	364	0	1	04	01	H5521_364_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	364	0	1	04	01	H5521_364_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	364	0	1	04	01	H5521_364_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	364	0	1	04	01	H5521_364_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	364	0	1	04	01	H5521_364_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	364	0	1	04	01	H5521_364_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	364	0	1	04	01	H5521_364_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											693.48	28						628.46	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	365	0	1	04	01	H5521_365_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	365	0	1	04	01	H5521_365_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	365	0	1	04	01	H5521_365_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	365	0	1	04	01	H5521_365_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	365	0	1	04	01	H5521_365_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	365	0	1	04	01	H5521_365_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	365	0	1	04	01	H5521_365_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											864.88	33						662.95	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	366	0	1	04	01	H5521_366_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	366	0	1	04	01	H5521_366_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	366	0	1	04	01	H5521_366_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	366	0	1	04	01	H5521_366_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	366	0	1	04	01	H5521_366_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	366	0	1	04	01	H5521_366_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	366	0	1	04	01	H5521_366_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											864.20	33						662.06	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	370	0	1	04	01	H5521_370_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	370	0	1	04	01	H5521_370_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	370	0	1	04	01	H5521_370_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	370	0	1	04	01	H5521_370_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	370	0	1	04	01	H5521_370_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	370	0	1	04	01	H5521_370_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	370	0	1	04	01	H5521_370_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											711.69	33						570.91	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	371	0	1	04	01	H5521_371_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	371	0	1	04	01	H5521_371_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	371	0	1	04	01	H5521_371_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	371	0	1	04	01	H5521_371_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	371	0	1	04	01	H5521_371_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	371	0	1	04	01	H5521_371_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	371	0	1	04	01	H5521_371_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.68	33						572.65	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	372	0	1	04	01	H5521_372_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	372	0	1	04	01	H5521_372_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	372	0	1	04	01	H5521_372_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	372	0	1	04	01	H5521_372_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	372	0	1	04	01	H5521_372_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	372	0	1	04	01	H5521_372_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	372	0	1	04	01	H5521_372_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											712.49	33						572.31	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	373	0	1	04	01	H5521_373_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	373	0	1	04	01	H5521_373_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	373	0	1	04	01	H5521_373_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	373	0	1	04	01	H5521_373_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	373	0	1	04	01	H5521_373_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	373	0	1	04	01	H5521_373_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	373	0	1	04	01	H5521_373_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											788.70	28						573.03	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	374	0	1	04	01	H5521_374_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	374	0	1	04	01	H5521_374_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	374	0	1	04	01	H5521_374_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	374	0	1	04	01	H5521_374_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	374	0	1	04	01	H5521_374_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	374	0	1	04	01	H5521_374_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	374	0	1	04	01	H5521_374_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											946.03	33						671.51	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	375	0	1	04	01	H5521_375_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	375	0	1	04	01	H5521_375_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	375	0	1	04	01	H5521_375_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	375	0	1	04	01	H5521_375_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	375	0	1	04	01	H5521_375_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	375	0	1	04	01	H5521_375_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	375	0	1	04	01	H5521_375_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											867.34	33						641.69	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	376	0	1	04	01	H5521_376_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	376	0	1	04	01	H5521_376_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	376	0	1	04	01	H5521_376_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	376	0	1	04	01	H5521_376_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	376	0	1	04	01	H5521_376_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.83	25	25	25				66.01	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	376	0	1	04	01	H5521_376_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.99	40	40	40				79.58	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	376	0	1	04	01	H5521_376_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											684.45	29						637.67	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	377	0	1	04	01	H5521_377_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	377	0	1	04	01	H5521_377_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	377	0	1	04	01	H5521_377_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	377	0	1	04	01	H5521_377_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	377	0	1	04	01	H5521_377_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	377	0	1	04	01	H5521_377_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	377	0	1	04	01	H5521_377_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											874.52	33						576.72	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	379	0	1	04	01	H5521_379_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	379	0	1	04	01	H5521_379_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	379	0	1	04	01	H5521_379_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	379	0	1	04	01	H5521_379_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	379	0	1	04	01	H5521_379_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	379	0	1	04	01	H5521_379_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	379	0	1	04	01	H5521_379_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											830.44	30						563.67	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	380	0	1	04	01	H5521_380_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	380	0	1	04	01	H5521_380_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	380	0	1	04	01	H5521_380_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	380	0	1	04	01	H5521_380_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	380	0	1	04	01	H5521_380_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	380	0	1	04	01	H5521_380_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	380	0	1	04	01	H5521_380_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											837.86	30						581.57	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	381	0	1	04	01	H5521_381_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	381	0	1	04	01	H5521_381_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	381	0	1	04	01	H5521_381_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	381	0	1	04	01	H5521_381_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	381	0	1	04	01	H5521_381_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.78	25	25	25				50.62	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	381	0	1	04	01	H5521_381_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.24	50	50	50				64.21	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	381	0	1	04	01	H5521_381_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											888.50	33						641.24	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	382	0	1	04	01	H5521_382_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	382	0	1	04	01	H5521_382_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	382	0	1	04	01	H5521_382_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	382	0	1	04	01	H5521_382_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	382	0	1	04	01	H5521_382_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.30	25	25	25				75.78	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	382	0	1	04	01	H5521_382_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											95.24	40	40	40				82.54	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	382	0	1	04	01	H5521_382_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.24	29						580.56	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	383	0	1	04	01	H5521_383_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	383	0	1	04	01	H5521_383_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	383	0	1	04	01	H5521_383_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	383	0	1	04	01	H5521_383_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	383	0	1	04	01	H5521_383_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.10	25	25	25				76.29	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	383	0	1	04	01	H5521_383_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											96.11	40	40	40				82.55	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	383	0	1	04	01	H5521_383_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											822.80	29						578.23	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	384	0	1	04	01	H5521_384_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	384	0	1	04	01	H5521_384_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	384	0	1	04	01	H5521_384_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	384	0	1	04	01	H5521_384_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	384	0	1	04	01	H5521_384_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.96	25	25	25				74.88	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	384	0	1	04	01	H5521_384_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.95	40	40	40				82.45	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	384	0	1	04	01	H5521_384_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											782.23	29						584.23	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	386	0	1	04	01	H5521_386_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	386	0	1	04	01	H5521_386_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	386	0	1	04	01	H5521_386_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											110.11	25	25	25				126.23	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	386	0	1	04	01	H5521_386_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.80	40	40	40				42.43	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	386	0	1	04	01	H5521_386_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											850.98	28						560.93	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	387	0	1	04	01	H5521_387_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	387	0	1	04	01	H5521_387_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	387	0	1	04	01	H5521_387_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	387	0	1	04	01	H5521_387_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	387	0	1	04	01	H5521_387_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	387	0	1	04	01	H5521_387_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	387	0	1	04	01	H5521_387_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.66	30						587.98	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	388	0	1	04	01	H5521_388_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	388	0	1	04	01	H5521_388_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	388	0	1	04	01	H5521_388_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	388	0	1	04	01	H5521_388_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	388	0	1	04	01	H5521_388_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	388	0	1	04	01	H5521_388_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	388	0	1	04	01	H5521_388_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											848.64	30						586.05	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	389	0	1	04	01	H5521_389_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	389	0	1	04	01	H5521_389_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	389	0	1	04	01	H5521_389_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	389	0	1	04	01	H5521_389_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	389	0	1	04	01	H5521_389_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	389	0	1	04	01	H5521_389_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	389	0	1	04	01	H5521_389_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											858.24	30						596.94	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	390	0	1	04	01	H5521_390_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	390	0	1	04	01	H5521_390_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	390	0	1	04	01	H5521_390_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	390	0	1	04	01	H5521_390_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	390	0	1	04	01	H5521_390_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.54	25	25	25				51.68	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	390	0	1	04	01	H5521_390_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.74	50	50	50				66.32	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	390	0	1	04	01	H5521_390_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											898.04	33						657.88	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	391	0	1	04	01	H5521_391_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	391	0	1	04	01	H5521_391_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	391	0	1	04	01	H5521_391_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	391	0	1	04	01	H5521_391_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	391	0	1	04	01	H5521_391_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	391	0	1	04	01	H5521_391_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	391	0	1	04	01	H5521_391_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											838.23	30						598.07	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	392	0	1	04	01	H5521_392_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	392	0	1	04	01	H5521_392_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	392	0	1	04	01	H5521_392_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	392	0	1	04	01	H5521_392_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	392	0	1	04	01	H5521_392_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											51.23	25	25	25				52.17	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	392	0	1	04	01	H5521_392_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.33	50	50	50				65.51	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	392	0	1	04	01	H5521_392_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											933.83	33						654.21	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	393	0	1	04	01	H5521_393_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	393	0	1	04	01	H5521_393_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	393	0	1	04	01	H5521_393_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	393	0	1	04	01	H5521_393_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	393	0	1	04	01	H5521_393_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.89	25	25	25				93.99	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	393	0	1	04	01	H5521_393_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.94	50	50	50				49.58	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	393	0	1	04	01	H5521_393_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.78	29						566.45	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	395	0	1	04	01	H5521_395_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	395	0	1	04	01	H5521_395_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	395	0	1	04	01	H5521_395_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	395	0	1	04	01	H5521_395_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	395	0	1	04	01	H5521_395_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	395	0	1	04	01	H5521_395_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	395	0	1	04	01	H5521_395_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											810.82	30						623.91	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	396	0	1	04	01	H5521_396_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	396	0	1	04	01	H5521_396_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	396	0	1	04	01	H5521_396_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	396	0	1	04	01	H5521_396_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	396	0	1	04	01	H5521_396_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.10	25	25	25				98.79	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	396	0	1	04	01	H5521_396_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.33	50	50	50				47.81	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	396	0	1	04	01	H5521_396_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											824.91	29						604.89	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	397	0	1	04	01	H5521_397_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	397	0	1	04	01	H5521_397_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	397	0	1	04	01	H5521_397_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	397	0	1	04	01	H5521_397_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	397	0	1	04	01	H5521_397_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.93	25	25	25				46.13	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	397	0	1	04	01	H5521_397_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.57	50	50	50				62.20	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	397	0	1	04	01	H5521_397_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											969.54	33						671.25	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	399	0	1	04	01	H5521_399_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	399	0	1	04	01	H5521_399_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	399	0	1	04	01	H5521_399_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	399	0	1	04	01	H5521_399_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	399	0	1	04	01	H5521_399_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.93	25	25	25				96.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	399	0	1	04	01	H5521_399_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.41	40	40	40				42.52	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	399	0	1	04	01	H5521_399_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											641.42	27						582.57	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	400	0	1	04	01	H5521_400_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	400	0	1	04	01	H5521_400_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	400	0	1	04	01	H5521_400_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	400	0	1	04	01	H5521_400_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	400	0	1	04	01	H5521_400_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											108.10	25	25	25				99.66	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	400	0	1	04	01	H5521_400_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.49	40	40	40				42.87	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	400	0	1	04	01	H5521_400_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											664.46	27						593.76	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	403	0	1	04	01	H5521_403_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	403	0	1	04	01	H5521_403_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	403	0	1	04	01	H5521_403_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	403	0	1	04	01	H5521_403_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	403	0	1	04	01	H5521_403_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.63	25	25	25				97.67	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	403	0	1	04	01	H5521_403_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.70	50	50	50				51.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	403	0	1	04	01	H5521_403_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											865.34	29						599.23	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	404	0	1	04	01	H5521_404_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	404	0	1	04	01	H5521_404_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	404	0	1	04	01	H5521_404_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	404	0	1	04	01	H5521_404_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	404	0	1	04	01	H5521_404_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.99	25	25	25				95.72	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	404	0	1	04	01	H5521_404_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.36	50	50	50				52.48	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	404	0	1	04	01	H5521_404_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											821.88	29						594.00	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	405	0	1	04	01	H5521_405_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	405	0	1	04	01	H5521_405_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	405	0	1	04	01	H5521_405_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	405	0	1	04	01	H5521_405_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	405	0	1	04	01	H5521_405_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.46	25	25	25				98.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	405	0	1	04	01	H5521_405_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.23	50	50	50				50.66	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	405	0	1	04	01	H5521_405_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											839.72	29						602.33	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	406	0	1	04	01	H5521_406_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	406	0	1	04	01	H5521_406_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	406	0	1	04	01	H5521_406_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	406	0	1	04	01	H5521_406_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	406	0	1	04	01	H5521_406_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.64	25	25	25				99.00	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	406	0	1	04	01	H5521_406_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.53	50	50	50				50.68	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	406	0	1	04	01	H5521_406_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											849.45	29						601.24	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	407	0	1	04	01	H5521_407_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	407	0	1	04	01	H5521_407_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	407	0	1	04	01	H5521_407_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	407	0	1	04	01	H5521_407_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	407	0	1	04	01	H5521_407_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.97	25	25	25				95.71	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	407	0	1	04	01	H5521_407_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.31	50	50	50				52.46	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	407	0	1	04	01	H5521_407_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.57	29						594.17	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	408	0	1	04	01	H5521_408_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	408	0	1	04	01	H5521_408_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	408	0	1	04	01	H5521_408_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	408	0	1	04	01	H5521_408_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	408	0	1	04	01	H5521_408_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.46	25	25	25				98.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	408	0	1	04	01	H5521_408_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.23	50	50	50				50.66	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	408	0	1	04	01	H5521_408_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											839.72	29						602.33	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	409	0	1	04	01	H5521_409_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	409	0	1	04	01	H5521_409_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	409	0	1	04	01	H5521_409_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	409	0	1	04	01	H5521_409_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	409	0	1	04	01	H5521_409_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.46	25	25	25				98.93	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	409	0	1	04	01	H5521_409_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.23	50	50	50				50.66	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	409	0	1	04	01	H5521_409_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											839.72	29						602.33	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	410	0	1	04	01	H5521_410_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	410	0	1	04	01	H5521_410_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	410	0	1	04	01	H5521_410_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	410	0	1	04	01	H5521_410_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	410	0	1	04	01	H5521_410_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.63	25	25	25				97.67	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	410	0	1	04	01	H5521_410_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.70	50	50	50				51.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	410	0	1	04	01	H5521_410_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											865.34	29						599.23	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	411	0	1	04	01	H5521_411_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	411	0	1	04	01	H5521_411_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	411	0	1	04	01	H5521_411_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	411	0	1	04	01	H5521_411_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	411	0	1	04	01	H5521_411_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											108.10	25	25	25				99.66	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	411	0	1	04	01	H5521_411_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.49	40	40	40				42.87	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	411	0	1	04	01	H5521_411_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											664.46	27						593.76	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	412	0	1	04	01	H5521_412_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	412	0	1	04	01	H5521_412_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	412	0	1	04	01	H5521_412_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	412	0	1	04	01	H5521_412_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	412	0	1	04	01	H5521_412_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											107.63	25	25	25				97.67	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	412	0	1	04	01	H5521_412_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.70	50	50	50				51.80	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	412	0	1	04	01	H5521_412_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											865.34	29						599.23	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	413	0	1	04	01	H5521_413_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	413	0	1	04	01	H5521_413_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	413	0	1	04	01	H5521_413_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	413	0	1	04	01	H5521_413_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	413	0	1	04	01	H5521_413_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											108.01	25	25	25				97.70	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	413	0	1	04	01	H5521_413_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.76	50	50	50				52.00	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	413	0	1	04	01	H5521_413_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											893.91	29						595.43	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	414	0	1	04	01	H5521_414_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	414	0	1	04	01	H5521_414_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	414	0	1	04	01	H5521_414_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	414	0	1	04	01	H5521_414_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	414	0	1	04	01	H5521_414_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											110.97	25	25	25				101.32	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	414	0	1	04	01	H5521_414_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.56	40	40	40				44.92	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	414	0	1	04	01	H5521_414_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											681.79	27						609.63	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	419	0	1	04	01	H5521_419_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	419	0	1	04	01	H5521_419_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	419	0	1	04	01	H5521_419_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	419	0	1	04	01	H5521_419_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	419	0	1	04	01	H5521_419_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	419	0	1	04	01	H5521_419_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	419	0	1	04	01	H5521_419_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	420	0	1	04	01	H5521_420_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	420	0	1	04	01	H5521_420_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	420	0	1	04	01	H5521_420_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	420	0	1	04	01	H5521_420_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	420	0	1	04	01	H5521_420_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	420	0	1	04	01	H5521_420_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	420	0	1	04	01	H5521_420_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	421	0	1	04	01	H5521_421_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	421	0	1	04	01	H5521_421_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	421	0	1	04	01	H5521_421_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	421	0	1	04	01	H5521_421_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	421	0	1	04	01	H5521_421_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	421	0	1	04	01	H5521_421_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	421	0	1	04	01	H5521_421_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	422	0	1	04	01	H5521_422_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	422	0	1	04	01	H5521_422_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	422	0	1	04	01	H5521_422_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	422	0	1	04	01	H5521_422_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	422	0	1	04	01	H5521_422_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	422	0	1	04	01	H5521_422_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	422	0	1	04	01	H5521_422_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	423	0	1	04	01	H5521_423_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	423	0	1	04	01	H5521_423_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	423	0	1	04	01	H5521_423_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	423	0	1	04	01	H5521_423_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	423	0	1	04	01	H5521_423_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.39	25	25	25				92.34	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	423	0	1	04	01	H5521_423_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.82	50	50	50				51.56	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	423	0	1	04	01	H5521_423_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											870.99	29						578.95	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	424	0	1	04	01	H5521_424_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	424	0	1	04	01	H5521_424_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	424	0	1	04	01	H5521_424_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	424	0	1	04	01	H5521_424_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	424	0	1	04	01	H5521_424_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.94	25	25	25				95.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	424	0	1	04	01	H5521_424_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.73	40	40	40				43.32	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	424	0	1	04	01	H5521_424_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											633.85	27						576.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	425	0	1	04	01	H5521_425_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	425	0	1	04	01	H5521_425_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	425	0	1	04	01	H5521_425_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	425	0	1	04	01	H5521_425_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	425	0	1	04	01	H5521_425_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.11	25	25	25				66.87	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	425	0	1	04	01	H5521_425_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											32.31	50	50	50				23.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	425	0	1	04	01	H5521_425_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.71	33						579.11	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	431	0	1	04	01	H5521_431_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	431	0	1	04	01	H5521_431_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	431	0	1	04	01	H5521_431_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	431	0	1	04	01	H5521_431_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	431	0	1	04	01	H5521_431_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.97	25	25	25				74.98	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	431	0	1	04	01	H5521_431_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.99	50	50	50				25.05	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	431	0	1	04	01	H5521_431_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											967.00	33						640.02	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	432	0	1	04	01	H5521_432_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	432	0	1	04	01	H5521_432_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	432	0	1	04	01	H5521_432_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	432	0	1	04	01	H5521_432_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	432	0	1	04	01	H5521_432_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	432	0	1	04	01	H5521_432_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	432	0	1	04	01	H5521_432_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											889.78	33						603.67	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	433	0	1	04	01	H5521_433_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	433	0	1	04	01	H5521_433_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	433	0	1	04	01	H5521_433_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	433	0	1	04	01	H5521_433_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	433	0	1	04	01	H5521_433_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	433	0	1	04	01	H5521_433_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	433	0	1	04	01	H5521_433_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											889.78	33						603.67	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	434	0	1	04	01	H5521_434_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	434	0	1	04	01	H5521_434_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	434	0	1	04	01	H5521_434_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	434	0	1	04	01	H5521_434_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	434	0	1	04	01	H5521_434_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	434	0	1	04	01	H5521_434_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	434	0	1	04	01	H5521_434_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											894.00	33						603.05	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	435	0	1	04	01	H5521_435_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	435	0	1	04	01	H5521_435_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	435	0	1	04	01	H5521_435_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	435	0	1	04	01	H5521_435_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	435	0	1	04	01	H5521_435_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	435	0	1	04	01	H5521_435_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	435	0	1	04	01	H5521_435_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											871.94	33						606.39	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	436	0	1	04	01	H5521_436_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	436	0	1	04	01	H5521_436_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	436	0	1	04	01	H5521_436_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	436	0	1	04	01	H5521_436_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	436	0	1	04	01	H5521_436_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	436	0	1	04	01	H5521_436_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	436	0	1	04	01	H5521_436_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											888.25	33						603.90	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	437	0	1	04	01	H5521_437_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	437	0	1	04	01	H5521_437_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	437	0	1	04	01	H5521_437_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	437	0	1	04	01	H5521_437_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	437	0	1	04	01	H5521_437_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	437	0	1	04	01	H5521_437_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	437	0	1	04	01	H5521_437_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											899.88	33						602.19	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	438	0	1	04	01	H5521_438_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	438	0	1	04	01	H5521_438_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	438	0	1	04	01	H5521_438_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	438	0	1	04	01	H5521_438_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	438	0	1	04	01	H5521_438_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	438	0	1	04	01	H5521_438_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	438	0	1	04	01	H5521_438_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											899.26	33						602.28	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	439	0	1	04	01	H5521_439_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	439	0	1	04	01	H5521_439_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	439	0	1	04	01	H5521_439_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	439	0	1	04	01	H5521_439_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	439	0	1	04	01	H5521_439_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	439	0	1	04	01	H5521_439_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	439	0	1	04	01	H5521_439_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											888.35	33						603.89	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	441	0	1	04	01	H5521_441_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	441	0	1	04	01	H5521_441_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	441	0	1	04	01	H5521_441_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	441	0	1	04	01	H5521_441_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	441	0	1	04	01	H5521_441_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											111.43	25	25	25				98.85	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	441	0	1	04	01	H5521_441_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.97	40	40	40				44.27	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	441	0	1	04	01	H5521_441_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											845.42	27						560.35	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	442	0	1	04	01	H5521_442_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	442	0	1	04	01	H5521_442_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	442	0	1	04	01	H5521_442_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	442	0	1	04	01	H5521_442_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	442	0	1	04	01	H5521_442_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											111.33	25	25	25				101.71	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	442	0	1	04	01	H5521_442_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.94	40	40	40				43.73	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	442	0	1	04	01	H5521_442_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											809.63	27						565.91	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	443	0	1	04	01	H5521_443_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	443	0	1	04	01	H5521_443_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	443	0	1	04	01	H5521_443_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	443	0	1	04	01	H5521_443_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	443	0	1	04	01	H5521_443_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											99.34	25	25	25				90.58	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	443	0	1	04	01	H5521_443_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											54.07	50	50	50				51.95	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	443	0	1	04	01	H5521_443_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											658.60	29						597.00	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	444	0	1	04	01	H5521_444_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	444	0	1	04	01	H5521_444_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	444	0	1	04	01	H5521_444_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	444	0	1	04	01	H5521_444_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	444	0	1	04	01	H5521_444_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											92.16	25	25	25				81.88	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	444	0	1	04	01	H5521_444_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.40	50	50	50				25.86	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	444	0	1	04	01	H5521_444_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											979.02	33						689.29	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	445	0	1	04	01	H5521_445_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	445	0	1	04	01	H5521_445_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	445	0	1	04	01	H5521_445_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	445	0	1	04	01	H5521_445_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	445	0	1	04	01	H5521_445_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.02	25	25	25				76.16	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	445	0	1	04	01	H5521_445_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.42	50	50	50				24.65	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	445	0	1	04	01	H5521_445_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											920.36	33						645.31	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	446	0	1	04	01	H5521_446_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	446	0	1	04	01	H5521_446_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	446	0	1	04	01	H5521_446_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	446	0	1	04	01	H5521_446_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	446	0	1	04	01	H5521_446_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.73	25	25	25				45.57	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	446	0	1	04	01	H5521_446_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.52	50	50	50				60.50	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	446	0	1	04	01	H5521_446_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											945.18	33						644.51	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	447	0	1	04	01	H5521_447_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	447	0	1	04	01	H5521_447_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	447	0	1	04	01	H5521_447_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	447	0	1	04	01	H5521_447_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	447	0	1	04	01	H5521_447_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.01	25	25	25				60.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	447	0	1	04	01	H5521_447_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.43	40	40	40				74.66	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	447	0	1	04	01	H5521_447_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											645.41	29						607.92	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	448	0	1	04	01	H5521_448_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	448	0	1	04	01	H5521_448_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	448	0	1	04	01	H5521_448_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	448	0	1	04	01	H5521_448_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	448	0	1	04	01	H5521_448_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.01	25	25	25				60.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	448	0	1	04	01	H5521_448_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.43	40	40	40				74.66	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	448	0	1	04	01	H5521_448_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											645.41	29						607.92	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	449	0	1	04	01	H5521_449_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	449	0	1	04	01	H5521_449_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	449	0	1	04	01	H5521_449_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	449	0	1	04	01	H5521_449_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	449	0	1	04	01	H5521_449_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.01	25	25	25				60.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	449	0	1	04	01	H5521_449_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.43	40	40	40				74.66	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	449	0	1	04	01	H5521_449_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											645.41	29						607.92	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	450	0	1	04	01	H5521_450_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	450	0	1	04	01	H5521_450_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	450	0	1	04	01	H5521_450_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	450	0	1	04	01	H5521_450_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	450	0	1	04	01	H5521_450_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.99	25	25	25				44.92	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	450	0	1	04	01	H5521_450_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.72	50	50	50				63.55	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	450	0	1	04	01	H5521_450_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											826.43	33						660.55	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	451	0	1	04	01	H5521_451_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	451	0	1	04	01	H5521_451_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	451	0	1	04	01	H5521_451_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	451	0	1	04	01	H5521_451_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	451	0	1	04	01	H5521_451_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.93	25	25	25				44.85	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	451	0	1	04	01	H5521_451_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.66	50	50	50				63.83	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	451	0	1	04	01	H5521_451_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											818.35	33						661.86	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	455	0	1	04	01	H5521_455_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	455	0	1	04	01	H5521_455_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	455	0	1	04	01	H5521_455_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	455	0	1	04	01	H5521_455_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	455	0	1	04	01	H5521_455_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.31	25	25	25				96.86	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	455	0	1	04	01	H5521_455_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.34	50	50	50				58.23	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	455	0	1	04	01	H5521_455_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											843.31	29						600.18	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	456	0	1	04	01	H5521_456_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	456	0	1	04	01	H5521_456_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	456	0	1	04	01	H5521_456_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	456	0	1	04	01	H5521_456_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	456	0	1	04	01	H5521_456_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.83	25	25	25				79.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	456	0	1	04	01	H5521_456_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.92	50	50	50				28.00	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	456	0	1	04	01	H5521_456_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											992.25	33						661.61	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	457	0	1	04	01	H5521_457_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	457	0	1	04	01	H5521_457_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	457	0	1	04	01	H5521_457_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	457	0	1	04	01	H5521_457_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	457	0	1	04	01	H5521_457_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.97	25	25	25				95.22	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	457	0	1	04	01	H5521_457_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.29	50	50	50				56.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	457	0	1	04	01	H5521_457_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											815.47	29						588.87	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	458	0	1	04	01	H5521_458_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	458	0	1	04	01	H5521_458_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	458	0	1	04	01	H5521_458_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	458	0	1	04	01	H5521_458_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	458	0	1	04	01	H5521_458_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.97	25	25	25				95.22	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	458	0	1	04	01	H5521_458_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.29	50	50	50				56.57	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	458	0	1	04	01	H5521_458_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											815.47	29						588.87	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	459	0	1	04	01	H5521_459_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	459	0	1	04	01	H5521_459_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	459	0	1	04	01	H5521_459_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	459	0	1	04	01	H5521_459_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	459	0	1	04	01	H5521_459_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.89	25	25	25				95.56	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	459	0	1	04	01	H5521_459_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.61	50	50	50				56.85	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	459	0	1	04	01	H5521_459_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											854.18	29						587.14	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	460	0	1	04	01	H5521_460_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	460	0	1	04	01	H5521_460_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	460	0	1	04	01	H5521_460_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	460	0	1	04	01	H5521_460_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	460	0	1	04	01	H5521_460_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.00	25	25	25				95.59	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	460	0	1	04	01	H5521_460_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.77	50	50	50				56.88	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	460	0	1	04	01	H5521_460_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											858.76	29						586.94	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	467	0	1	04	01	H5521_467_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	467	0	1	04	01	H5521_467_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	467	0	1	04	01	H5521_467_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	467	0	1	04	01	H5521_467_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	467	0	1	04	01	H5521_467_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	467	0	1	04	01	H5521_467_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	467	0	1	04	01	H5521_467_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											645.80	28						606.30	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	470	0	1	04	01	H5521_470_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	470	0	1	04	01	H5521_470_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	470	0	1	04	01	H5521_470_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	470	0	1	04	01	H5521_470_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	470	0	1	04	01	H5521_470_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.36	25	25	25				98.77	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	470	0	1	04	01	H5521_470_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.93	40	40	40				41.42	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	470	0	1	04	01	H5521_470_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											650.77	27						588.19	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	471	0	1	04	01	H5521_471_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	471	0	1	04	01	H5521_471_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	471	0	1	04	01	H5521_471_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	471	0	1	04	01	H5521_471_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	471	0	1	04	01	H5521_471_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	471	0	1	04	01	H5521_471_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	471	0	1	04	01	H5521_471_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											868.17	33						681.76	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	474	0	1	04	01	H5521_474_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	474	0	1	04	01	H5521_474_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	474	0	1	04	01	H5521_474_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	474	0	1	04	01	H5521_474_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	474	0	1	04	01	H5521_474_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	474	0	1	04	01	H5521_474_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	474	0	1	04	01	H5521_474_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											702.94	30						662.09	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	475	0	1	04	01	H5521_475_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	475	0	1	04	01	H5521_475_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	475	0	1	04	01	H5521_475_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	475	0	1	04	01	H5521_475_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	475	0	1	04	01	H5521_475_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.63	25	25	25				66.89	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	475	0	1	04	01	H5521_475_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.82	40	40	40				76.87	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	475	0	1	04	01	H5521_475_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											779.23	29						594.86	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	476	0	1	04	01	H5521_476_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	476	0	1	04	01	H5521_476_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	476	0	1	04	01	H5521_476_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	476	0	1	04	01	H5521_476_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	476	0	1	04	01	H5521_476_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.06	25	25	25				67.76	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	476	0	1	04	01	H5521_476_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.76	40	40	40				76.42	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	476	0	1	04	01	H5521_476_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.83	29						613.02	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5521	477	0	1	04	01	H5521_477_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	477	0	1	04	01	H5521_477_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	477	0	1	04	01	H5521_477_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	477	0	1	04	01	H5521_477_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5521	477	0	1	04	01	H5521_477_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.22	25	25	25				66.40	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5521	477	0	1	04	01	H5521_477_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.54	40	40	40				74.54	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5521	477	0	1	04	01	H5521_477_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											799.18	29						614.77	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	001	0	1	04	01	H5522_001_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	001	0	1	04	01	H5522_001_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5522	001	0	1	04	01	H5522_001_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	001	0	1	04	01	H5522_001_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5522	001	0	1	04	01	H5522_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	001	0	1	04	01	H5522_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	001	0	1	04	01	H5522_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1198.49	33						616.21	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	002	0	1	04	01	H5522_002_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	002	0	1	04	01	H5522_002_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	002	0	1	04	01	H5522_002_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	002	0	1	04	01	H5522_002_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	002	0	1	04	01	H5522_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	002	0	1	04	01	H5522_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	002	0	1	04	01	H5522_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											875.05	33						613.05	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	004	0	1	04	01	H5522_004_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	004	0	1	04	01	H5522_004_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	004	0	1	04	01	H5522_004_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	004	0	1	04	01	H5522_004_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	004	0	1	04	01	H5522_004_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	004	0	1	04	01	H5522_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	004	0	1	04	01	H5522_004_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											815.48	33						635.69	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	005	0	1	04	01	H5522_005_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	005	0	1	04	01	H5522_005_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5522	005	0	1	04	01	H5522_005_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	005	0	1	04	01	H5522_005_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5522	005	0	1	04	01	H5522_005_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	005	0	1	04	01	H5522_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	005	0	1	04	01	H5522_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											887.40	33						633.48	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	013	0	1	04	01	H5522_013_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	013	0	1	04	01	H5522_013_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	013	0	1	04	01	H5522_013_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	013	0	1	04	01	H5522_013_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	013	0	1	04	01	H5522_013_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	013	0	1	04	01	H5522_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	013	0	1	04	01	H5522_013_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											881.99	33						681.80	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	014	0	1	04	01	H5522_014_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	014	0	1	04	01	H5522_014_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5522	014	0	1	04	01	H5522_014_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	014	0	1	04	01	H5522_014_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5522	014	0	1	04	01	H5522_014_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	014	0	1	04	01	H5522_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	014	0	1	04	01	H5522_014_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											875.75	33						1025.38	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	017	0	1	04	01	H5522_017_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	017	0	1	04	01	H5522_017_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	017	0	1	04	01	H5522_017_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	017	0	1	04	01	H5522_017_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	017	0	1	04	01	H5522_017_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	017	0	1	04	01	H5522_017_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	017	0	1	04	01	H5522_017_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											801.84	33						745.91	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	022	0	1	04	01	H5522_022_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	022	0	1	04	01	H5522_022_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	022	0	1	04	01	H5522_022_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	022	0	1	04	01	H5522_022_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	022	0	1	04	01	H5522_022_0	6			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	022	0	1	04	01	H5522_022_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	022	0	1	04	01	H5522_022_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											866.92	33						637.16	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	023	0	1	04	01	H5522_023_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	023	0	1	04	01	H5522_023_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	023	0	1	04	01	H5522_023_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	023	0	1	04	01	H5522_023_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	023	0	1	04	01	H5522_023_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.37	25	25	25				46.38	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	023	0	1	04	01	H5522_023_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.00	50	50	50				63.46	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	023	0	1	04	01	H5522_023_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											907.57	33						653.34	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	025	0	1	04	01	H5522_025_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	025	0	1	04	01	H5522_025_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	025	0	1	04	01	H5522_025_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.07	25	25	25				119.04	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	025	0	1	04	01	H5522_025_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.03	40	40	40				43.42	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	025	0	1	04	01	H5522_025_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											701.78	28						514.21	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	026	0	1	04	01	H5522_026_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	026	0	1	04	01	H5522_026_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	026	0	1	04	01	H5522_026_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.93	25	25	25				118.67	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	026	0	1	04	01	H5522_026_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.96	40	40	40				43.03	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	026	0	1	04	01	H5522_026_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.62	28						568.29	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	027	0	1	04	01	H5522_027_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	027	0	1	04	01	H5522_027_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	027	0	1	04	01	H5522_027_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.93	25	25	25				118.67	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	027	0	1	04	01	H5522_027_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.96	40	40	40				43.03	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	027	0	1	04	01	H5522_027_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											796.62	28						568.29	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	028	0	1	04	01	H5522_028_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	028	0	1	04	01	H5522_028_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	028	0	1	04	01	H5522_028_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	028	0	1	04	01	H5522_028_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	028	0	1	04	01	H5522_028_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.29	25	25	25				46.31	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	028	0	1	04	01	H5522_028_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.94	50	50	50				63.75	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	028	0	1	04	01	H5522_028_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											895.43	33						655.56	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5522	029	0	1	04	01	H5522_029_0	6			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	029	0	1	04	01	H5522_029_0	6			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	029	0	1	04	01	H5522_029_0	6			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	029	0	1	04	01	H5522_029_0	6			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5522	029	0	1	04	01	H5522_029_0	6			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.19	25	25	25				46.21	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5522	029	0	1	04	01	H5522_029_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											83.86	50	50	50				64.18	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5522	029	0	1	04	01	H5522_029_0	6			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											878.58	33						658.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5525	004	0	1	04	01	H5525_004_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5525	004	0	1	04	01	H5525_004_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5525	004	0	1	04	01	H5525_004_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	004	0	1	04	01	H5525_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	004	0	1	04	01	H5525_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	005	0	1	04	01	H5525_005_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5525	005	0	1	04	01	H5525_005_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5525	005	0	1	04	01	H5525_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	005	0	1	04	01	H5525_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	005	0	1	04	01	H5525_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	006	0	1	04	01	H5525_006_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	3.00		9.00																									10.00		30.00				3.00		0.00				3.00				3.00		0.10				0.33	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		9.00				10.00		30.00	3.00		0.00	3.00		3.00
H5525	006	0	1	04	01	H5525_006_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5525	006	0	1	04	01	H5525_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	006	0	1	04	01	H5525_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	006	0	1	04	01	H5525_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	008	0	1	04	01	H5525_008_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5525	008	0	1	04	01	H5525_008_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5525	008	0	1	04	01	H5525_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	008	0	1	04	01	H5525_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	008	0	1	04	01	H5525_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	017	0	1	04	01	H5525_017_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	017	0	1	04	01	H5525_017_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	017	0	1	04	01	H5525_017_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	017	0	1	04	01	H5525_017_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	017	0	1	04	01	H5525_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	017	0	1	04	01	H5525_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	017	0	1	04	01	H5525_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	024	0	1	04	01	H5525_024_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5525	024	0	1	04	01	H5525_024_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5525	024	0	1	04	01	H5525_024_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	024	0	1	04	01	H5525_024_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	024	0	1	04	01	H5525_024_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	026	0	1	04	01	H5525_026_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5525	026	0	1	04	01	H5525_026_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5525	026	0	1	04	01	H5525_026_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	026	0	1	04	01	H5525_026_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	026	0	1	04	01	H5525_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	027	0	1	04	01	H5525_027_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	027	0	1	04	01	H5525_027_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	027	0	1	04	01	H5525_027_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5525	027	0	1	04	01	H5525_027_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	027	0	1	04	01	H5525_027_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	027	0	1	04	01	H5525_027_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	027	0	1	04	01	H5525_027_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	030	0	1	04	01	H5525_030_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	1.00		3.00																									10.00		30.00				1.00		0.00				1.00				1.00		0.03				0.33	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				10.00		30.00	1.00		0.00	1.00		1.00
H5525	030	0	1	04	01	H5525_030_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	4.00		12.00																									20.00		60.00				4.00		0.00				4.00				4.00		0.13				0.67	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				20.00		60.00	4.00		0.00	4.00		4.00
H5525	030	0	1	04	01	H5525_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	030	0	1	04	01	H5525_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	030	0	1	04	01	H5525_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	034	0	1	04	01	H5525_034_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5525	034	0	1	04	01	H5525_034_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5525	034	0	1	04	01	H5525_034_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	034	0	1	04	01	H5525_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	034	0	1	04	01	H5525_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	035	0	1	04	01	H5525_035_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	035	0	1	04	01	H5525_035_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	035	0	1	04	01	H5525_035_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	035	0	1	04	01	H5525_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	035	0	1	04	01	H5525_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	041	0	1	04	01	H5525_041_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5525	041	0	1	04	01	H5525_041_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5525	041	0	1	04	01	H5525_041_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	041	0	1	04	01	H5525_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	041	0	1	04	01	H5525_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	042	0	1	04	01	H5525_042_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5525	042	0	1	04	01	H5525_042_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5525	042	0	1	04	01	H5525_042_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	042	0	1	04	01	H5525_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	042	0	1	04	01	H5525_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	044	0	1	04	01	H5525_044_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	044	0	1	04	01	H5525_044_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	044	0	1	04	01	H5525_044_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5525	044	0	1	04	01	H5525_044_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	044	0	1	04	01	H5525_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	044	0	1	04	01	H5525_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	044	0	1	04	01	H5525_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	049	0	1	04	01	H5525_049_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	049	0	1	04	01	H5525_049_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	049	0	1	04	01	H5525_049_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	049	0	1	04	01	H5525_049_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	049	0	1	04	01	H5525_049_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	050	0	1	04	01	H5525_050_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	050	0	1	04	01	H5525_050_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	050	0	1	04	01	H5525_050_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	050	0	1	04	01	H5525_050_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	050	0	1	04	01	H5525_050_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	051	1	1	04	01	H5525_051_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	051	1	1	04	01	H5525_051_1	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	051	1	1	04	01	H5525_051_1	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	051	1	1	04	01	H5525_051_1	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	051	1	1	04	01	H5525_051_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	051	1	1	04	01	H5525_051_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	051	1	1	04	01	H5525_051_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	051	2	1	04	01	H5525_051_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	051	2	1	04	01	H5525_051_2	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	051	2	1	04	01	H5525_051_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	051	2	1	04	01	H5525_051_2	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	051	2	1	04	01	H5525_051_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	051	2	1	04	01	H5525_051_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	051	2	1	04	01	H5525_051_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	052	0	1	04	01	H5525_052_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	052	0	1	04	01	H5525_052_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	052	0	1	04	01	H5525_052_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	052	0	1	04	01	H5525_052_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	052	0	1	04	01	H5525_052_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	052	0	1	04	01	H5525_052_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	052	0	1	04	01	H5525_052_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	054	0	1	04	01	H5525_054_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	054	0	1	04	01	H5525_054_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	054	0	1	04	01	H5525_054_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5525	054	0	1	04	01	H5525_054_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	054	0	1	04	01	H5525_054_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	054	0	1	04	01	H5525_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	054	0	1	04	01	H5525_054_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	055	0	1	04	01	H5525_055_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	055	0	1	04	01	H5525_055_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	055	0	1	04	01	H5525_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	055	0	1	04	01	H5525_055_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	055	0	1	04	01	H5525_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	056	0	1	04	01	H5525_056_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	056	0	1	04	01	H5525_056_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	056	0	1	04	01	H5525_056_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	056	0	1	04	01	H5525_056_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	056	0	1	04	01	H5525_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	057	0	1	04	01	H5525_057_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	057	0	1	04	01	H5525_057_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	057	0	1	04	01	H5525_057_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	057	0	1	04	01	H5525_057_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	057	0	1	04	01	H5525_057_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	057	0	1	04	01	H5525_057_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	057	0	1	04	01	H5525_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	058	0	1	04	01	H5525_058_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	058	0	1	04	01	H5525_058_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	058	0	1	04	01	H5525_058_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	058	0	1	04	01	H5525_058_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	058	0	1	04	01	H5525_058_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	058	0	1	04	01	H5525_058_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	058	0	1	04	01	H5525_058_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	059	0	1	04	01	H5525_059_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	059	0	1	04	01	H5525_059_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	059	0	1	04	01	H5525_059_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	059	0	1	04	01	H5525_059_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	059	0	1	04	01	H5525_059_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	059	0	1	04	01	H5525_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	059	0	1	04	01	H5525_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	060	0	1	04	01	H5525_060_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	060	0	1	04	01	H5525_060_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	060	0	1	04	01	H5525_060_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	060	0	1	04	01	H5525_060_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	060	0	1	04	01	H5525_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	060	0	1	04	01	H5525_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	060	0	1	04	01	H5525_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	061	0	1	04	01	H5525_061_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	061	0	1	04	01	H5525_061_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	061	0	1	04	01	H5525_061_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	061	0	1	04	01	H5525_061_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	061	0	1	04	01	H5525_061_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	061	0	1	04	01	H5525_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	061	0	1	04	01	H5525_061_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	062	0	1	04	01	H5525_062_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	062	0	1	04	01	H5525_062_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	062	0	1	04	01	H5525_062_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	062	0	1	04	01	H5525_062_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	062	0	1	04	01	H5525_062_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	062	0	1	04	01	H5525_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	062	0	1	04	01	H5525_062_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	063	0	1	04	01	H5525_063_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	063	0	1	04	01	H5525_063_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	063	0	1	04	01	H5525_063_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	063	0	1	04	01	H5525_063_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	063	0	1	04	01	H5525_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	063	0	1	04	01	H5525_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	063	0	1	04	01	H5525_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	067	0	1	04	01	H5525_067_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	067	0	1	04	01	H5525_067_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	067	0	1	04	01	H5525_067_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	067	0	1	04	01	H5525_067_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	067	0	1	04	01	H5525_067_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	067	0	1	04	01	H5525_067_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	067	0	1	04	01	H5525_067_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	068	0	1	04	01	H5525_068_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	068	0	1	04	01	H5525_068_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	068	0	1	04	01	H5525_068_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	068	0	1	04	01	H5525_068_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	068	0	1	04	01	H5525_068_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	068	0	1	04	01	H5525_068_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	068	0	1	04	01	H5525_068_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	069	0	1	04	01	H5525_069_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5525	069	0	1	04	01	H5525_069_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	069	0	1	04	01	H5525_069_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5525	069	0	1	04	01	H5525_069_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5525	069	0	1	04	01	H5525_069_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	069	0	1	04	01	H5525_069_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	069	0	1	04	01	H5525_069_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	070	0	1	04	01	H5525_070_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00
H5525	070	0	1	04	01	H5525_070_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									1.00		3.00				0.00		0.00				0.00				0.00		0.00				0.03	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	070	0	1	04	01	H5525_070_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5525	070	0	1	04	01	H5525_070_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	070	0	1	04	01	H5525_070_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	070	0	1	04	01	H5525_070_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	070	0	1	04	01	H5525_070_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	071	0	1	04	01	H5525_071_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	071	0	1	04	01	H5525_071_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	071	0	1	04	01	H5525_071_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5525	071	0	1	04	01	H5525_071_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5525	071	0	1	04	01	H5525_071_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	071	0	1	04	01	H5525_071_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	071	0	1	04	01	H5525_071_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	074	0	1	04	01	H5525_074_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	074	0	1	04	01	H5525_074_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H5525	074	0	1	04	01	H5525_074_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	074	0	1	04	01	H5525_074_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	074	0	1	04	01	H5525_074_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	075	0	1	04	01	H5525_075_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	075	0	1	04	01	H5525_075_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	075	0	1	04	01	H5525_075_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	075	0	1	04	01	H5525_075_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	075	0	1	04	01	H5525_075_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	076	0	1	04	01	H5525_076_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	076	0	1	04	01	H5525_076_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H5525	076	0	1	04	01	H5525_076_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	076	0	1	04	01	H5525_076_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	076	0	1	04	01	H5525_076_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	077	0	1	04	01	H5525_077_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	077	0	1	04	01	H5525_077_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5525	077	0	1	04	01	H5525_077_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	077	0	1	04	01	H5525_077_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	077	0	1	04	01	H5525_077_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5525	080	0	1	04	01	H5525_080_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5525	080	0	1	04	01	H5525_080_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5525	080	0	1	04	01	H5525_080_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5525	080	0	1	04	01	H5525_080_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5525	080	0	1	04	01	H5525_080_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5526	004	0	1	04	01	H5526_004_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					2.00		6.00											7.00		17.50				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	004	0	1	04	01	H5526_004_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								13.00		39.00					8.00		24.00											13.00		32.50				8.00		20.00				13.00				13.00			0.42	0.26		0.42	0.26	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	004	0	1	04	01	H5526_004_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H5526	004	0	1	04	01	H5526_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								99.00		297.00					94.00		282.00											99.00		247.50				94.00		235.00				99.00				99.00			3.19	3.03		3.19	3.03	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	004	0	1	04	01	H5526_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1218.41	33						1218.41	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	016	0	1	04	01	H5526_016_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								9.00		27.00					4.00		12.00											9.00		22.50				4.00		0.00				9.00				9.00			0.29	0.13		0.29	0.13	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	016	0	1	04	01	H5526_016_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								15.00		45.00					10.00		30.00											15.00		37.50				10.00		25.00				15.00				15.00			0.48	0.32		0.48	0.32	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	016	0	1	04	01	H5526_016_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H5526	016	0	1	04	01	H5526_016_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	016	0	1	04	01	H5526_016_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1032.61	33						1032.61	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	018	0	1	04	01	H5526_018_0	8			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					2.00		6.00											7.00		17.50				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	018	0	1	04	01	H5526_018_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								15.00		45.00					10.00		30.00											15.00		37.50				10.00		25.00				15.00				15.00			0.48	0.32		0.48	0.32	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	018	0	1	04	01	H5526_018_0	8			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35		35
H5526	018	0	1	04	01	H5526_018_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	018	0	1	04	01	H5526_018_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1117.65	33						1117.65	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	020	0	1	04	01	H5526_020_0	11			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								5.00		15.00					0.00		0.00											5.00		12.50				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	020	0	1	04	01	H5526_020_0	11			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								17.00		51.00					5.00		15.00											17.00		42.50				5.00		0.00				17.00				17.00			0.55	0.16		0.55	0.16	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	020	0	1	04	01	H5526_020_0	11			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5526	020	0	1	04	01	H5526_020_0	11			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	020	0	1	04	01	H5526_020_0	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1069.10	29						1069.10	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	021	0	1	04	01	H5526_021_0	9			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								5.00		15.00					0.00		0.00											5.00		12.50				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	021	0	1	04	01	H5526_021_0	9			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								17.00		51.00					8.00		24.00											17.00		42.50				8.00		0.00				17.00				17.00			0.55	0.26		0.55	0.26	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	021	0	1	04	01	H5526_021_0	9			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5526	021	0	1	04	01	H5526_021_0	9			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	021	0	1	04	01	H5526_021_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1009.05	30						1009.05	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	022	0	1	04	01	H5526_022_0	7			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		100	1	2				31		100	31		31								7.00		21.00					0.00		0.00											7.00		17.50				0.00		0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	022	0	1	04	01	H5526_022_0	7			Generic	4	01	1	2	2	1		110	01		110	1				31		100	1	2				31		100	31		31								19.00		57.00					14.00		42.00											19.00		47.50				14.00		35.00				19.00				19.00			0.61	0.45		0.61	0.45	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	022	0	1	04	01	H5526_022_0	7			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		117.50				42.00		105.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5526	022	0	1	04	01	H5526_022_0	7			Non-Preferred Drug	4	11	1	2	4	1		110	01		110	1				31		90	1	2				31		90	31		31								100.00		300.00					94.00		282.00											100.00		250.00				94.00		235.00				100.00				100.00			3.23	3.03		3.23	3.03	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5526	022	0	1	04	01	H5526_022_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											923.79	27						923.79	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	003	0	1	04	01	H5533_003_0	9			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	003	0	1	04	01	H5533_003_0	9			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	003	0	1	04	01	H5533_003_0	9			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	003	0	1	04	01	H5533_003_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	003	0	1	04	01	H5533_003_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											875.22	33						1124.11	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	005	0	1	04	01	H5533_005_0	10			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	005	0	1	04	01	H5533_005_0	10			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	005	0	1	04	01	H5533_005_0	10			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	005	0	1	04	01	H5533_005_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	005	0	1	04	01	H5533_005_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1139.67	33						1528.67	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	008	0	1	04	01	H5533_008_0	9			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	008	0	1	04	01	H5533_008_0	9			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	008	0	1	04	01	H5533_008_0	9			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	008	0	1	04	01	H5533_008_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	008	0	1	04	01	H5533_008_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1016.76	33						961.06	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	009	0	1	04	01	H5533_009_0	10			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	009	0	1	04	01	H5533_009_0	10			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	009	0	1	04	01	H5533_009_0	10			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	009	0	1	04	01	H5533_009_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	009	0	1	04	01	H5533_009_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											849.40	33						1083.77	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	011	0	1	04	01	H5533_011_0	10			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	011	0	1	04	01	H5533_011_0	10			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	011	0	1	04	01	H5533_011_0	10			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	011	0	1	04	01	H5533_011_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	011	0	1	04	01	H5533_011_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											953.18	33						969.15	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	013	0	1	04	01	H5533_013_0	10			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	013	0	1	04	01	H5533_013_0	10			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	013	0	1	04	01	H5533_013_0	10			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	013	0	1	04	01	H5533_013_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	013	0	1	04	01	H5533_013_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											808.20	33						1191.92	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	1	1	04	01	H5533_015_1	11			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	1	1	04	01	H5533_015_1	11			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	1	1	04	01	H5533_015_1	11			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	015	1	1	04	01	H5533_015_1	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	1	1	04	01	H5533_015_1	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1066.14	33						1284.83	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	2	1	04	01	H5533_015_2	11			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	30.00					0.00	0.00	0.00													30.00						0.00				15.00				0.00			0.50	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	2	1	04	01	H5533_015_2	11			Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	40.00					0.00	0.00	0.00													40.00						0.00				20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	2	1	04	01	H5533_015_2	11			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					47.00	94.00	129.50													141.00						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.25			105.00			87.50	35.00		35.00
H5533	015	2	1	04	01	H5533_015_2	11			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	100	1	2						100	30		31								100.00	200.00	300.00					100.00	200.00	300.00													300.00						300.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5533	015	2	1	04	01	H5533_015_2	11			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1066.14	33						1284.83	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5549	012	0	1	01	01	H5549_012_0	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	15.00	30.00	45.00																					45.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													15.00	30.00	45.00						45.00				15.00		15.00
H5549	012	0	1	01	01	H5549_012_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	20.00	40.00	60.00																					60.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00	40.00	60.00						60.00				20.00		20.00
H5549	012	0	1	01	01	H5549_012_0	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	141.00																					141.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5549	012	0	1	01	01	H5549_012_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5549	012	0	1	01	01	H5549_012_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				281.77	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00												35.00		35.00
H5549	012	0	1	01	01	H5549_012_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	005	0	1	01	01	H5577_005_0	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	005	0	1	01	01	H5577_005_0	7			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	005	0	1	01	01	H5577_005_0	7			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	005	0	1	01	01	H5577_005_0	7			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	005	0	1	01	01	H5577_005_0	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	4.00	8.00	12.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	005	0	1	01	01	H5577_005_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	14.00	28.00	42.00																					28.00																14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	005	0	1	01	01	H5577_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	005	0	1	01	01	H5577_005_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	005	0	1	01	01	H5577_005_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	008	0	1	02	01	H5577_008_0	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	008	0	1	02	01	H5577_008_0	5			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	008	0	1	02	01	H5577_008_0	5			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	008	0	1	02	01	H5577_008_0	5			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	008	0	1	02	01	H5577_008_0	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	008	0	1	02	01	H5577_008_0	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	008	0	1	02	01	H5577_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	008	0	1	02	01	H5577_008_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	008	0	1	02	01	H5577_008_0	5			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	038	0	1	01	01	H5577_038_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	038	0	1	01	01	H5577_038_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	038	0	1	01	01	H5577_038_0	6			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	038	0	1	01	01	H5577_038_0	6			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	038	0	1	01	01	H5577_038_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	038	0	1	01	01	H5577_038_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	038	0	1	01	01	H5577_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	038	0	1	01	01	H5577_038_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	038	0	1	01	01	H5577_038_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	042	0	1	01	01	H5577_042_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	042	0	1	01	01	H5577_042_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	042	0	1	01	01	H5577_042_0	6			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	042	0	1	01	01	H5577_042_0	6			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	042	0	1	01	01	H5577_042_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	042	0	1	01	01	H5577_042_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	042	0	1	01	01	H5577_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	042	0	1	01	01	H5577_042_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	042	0	1	01	01	H5577_042_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	043	0	1	01	01	H5577_043_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	043	0	1	01	01	H5577_043_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	043	0	1	01	01	H5577_043_0	6			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	043	0	1	01	01	H5577_043_0	6			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	043	0	1	01	01	H5577_043_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	5.00	10.00	15.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	043	0	1	01	01	H5577_043_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	15.00	30.00	45.00																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	043	0	1	01	01	H5577_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	043	0	1	01	01	H5577_043_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	043	0	1	01	01	H5577_043_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	044	0	1	01	01	H5577_044_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	5.00	10.00	15.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	044	0	1	01	01	H5577_044_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	5.00	10.00	15.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	044	0	1	01	01	H5577_044_0	6			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	10.00	20.00	30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	044	0	1	01	01	H5577_044_0	6			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	10.00	20.00	30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	044	0	1	01	01	H5577_044_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	30.00	60.00	90.00																					60.00																30.00				30.00		1.00						0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	044	0	1	01	01	H5577_044_0	6			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	90				2	1			90				30		31				54.69	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	044	0	1	01	01	H5577_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	044	0	1	01	01	H5577_044_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	5.00	10.00	15.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													5.00	10.00	15.00						10.00				5.00		5.00
H5577	044	0	1	01	01	H5577_044_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	5.00	10.00	15.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	051	0	1	01	01	H5577_051_0	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	051	0	1	01	01	H5577_051_0	5			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	051	0	1	01	01	H5577_051_0	5			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	051	0	1	01	01	H5577_051_0	5			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	051	0	1	01	01	H5577_051_0	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	5.00	10.00	15.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	051	0	1	01	01	H5577_051_0	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	15.00	30.00	45.00																					30.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	051	0	1	01	01	H5577_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	051	0	1	01	01	H5577_051_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	051	0	1	01	01	H5577_051_0	5			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	052	0	1	01	01	H5577_052_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	052	0	1	01	01	H5577_052_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	052	0	1	01	01	H5577_052_0	6			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	052	0	1	01	01	H5577_052_0	6			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	052	0	1	01	01	H5577_052_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	052	0	1	01	01	H5577_052_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	052	0	1	01	01	H5577_052_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	052	0	1	01	01	H5577_052_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	052	0	1	01	01	H5577_052_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	053	0	1	01	01	H5577_053_0	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	053	0	1	01	01	H5577_053_0	5			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	053	0	1	01	01	H5577_053_0	5			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	053	0	1	01	01	H5577_053_0	5			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	053	0	1	01	01	H5577_053_0	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	053	0	1	01	01	H5577_053_0	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	053	0	1	01	01	H5577_053_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	053	0	1	01	01	H5577_053_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	053	0	1	01	01	H5577_053_0	5			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	056	1	1	01	01	H5577_056_1	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	1	1	01	01	H5577_056_1	5			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	056	1	1	01	01	H5577_056_1	5			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	1	1	01	01	H5577_056_1	5			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	056	1	1	01	01	H5577_056_1	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	1	1	01	01	H5577_056_1	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	1	1	01	01	H5577_056_1	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	1	1	01	01	H5577_056_1	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	056	1	1	01	01	H5577_056_1	5			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	056	2	1	01	01	H5577_056_2	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	2	1	01	01	H5577_056_2	5			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	056	2	1	01	01	H5577_056_2	5			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	2	1	01	01	H5577_056_2	5			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	056	2	1	01	01	H5577_056_2	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	2	1	01	01	H5577_056_2	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	2	1	01	01	H5577_056_2	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	056	2	1	01	01	H5577_056_2	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	056	2	1	01	01	H5577_056_2	5			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	057	0	1	01	01	H5577_057_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	057	0	1	01	01	H5577_057_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5577	057	0	1	01	01	H5577_057_0	6			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	057	0	1	01	01	H5577_057_0	6			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5577	057	0	1	01	01	H5577_057_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	057	0	1	01	01	H5577_057_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	057	0	1	01	01	H5577_057_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				911.00	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5577	057	0	1	01	01	H5577_057_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5577	057	0	1	01	01	H5577_057_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	1			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5591	005	0	1	02	01	H5591_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	005	0	1	02	01	H5591_005_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	005	0	1	02	01	H5591_005_0	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	005	0	1	02	01	H5591_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	005	0	1	02	01	H5591_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	005	0	1	02	01	H5591_005_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	005	0	1	02	01	H5591_005_0	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.19	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5591	006	1	1	02	01	H5591_006_1	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	1	1	02	01	H5591_006_1	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	1	1	02	01	H5591_006_1	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	006	1	1	02	01	H5591_006_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	1	1	02	01	H5591_006_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	006	1	1	02	01	H5591_006_1	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	1	1	02	01	H5591_006_1	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.15	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5591	006	2	1	02	01	H5591_006_2	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	2	1	02	01	H5591_006_2	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	2	1	02	01	H5591_006_2	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	006	2	1	02	01	H5591_006_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	2	1	02	01	H5591_006_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	006	2	1	02	01	H5591_006_2	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	2	1	02	01	H5591_006_2	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.15	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5591	006	4	1	02	01	H5591_006_4	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	4	1	02	01	H5591_006_4	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	4	1	02	01	H5591_006_4	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	006	4	1	02	01	H5591_006_4	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	4	1	02	01	H5591_006_4	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	006	4	1	02	01	H5591_006_4	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	4	1	02	01	H5591_006_4	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.15	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5591	006	5	1	02	01	H5591_006_5	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	5	1	02	01	H5591_006_5	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	5	1	02	01	H5591_006_5	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	006	5	1	02	01	H5591_006_5	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	5	1	02	01	H5591_006_5	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	006	5	1	02	01	H5591_006_5	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	006	5	1	02	01	H5591_006_5	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.15	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5591	009	0	1	02	01	H5591_009_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5591	009	0	1	02	01	H5591_009_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5591	009	0	1	02	01	H5591_009_0	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	009	0	1	02	01	H5591_009_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5591	009	0	1	02	01	H5591_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	28						600.00	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5591	013	0	1	02	01	H5591_013_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5591	013	0	1	02	01	H5591_013_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5591	013	0	1	02	01	H5591_013_0	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	013	0	1	02	01	H5591_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5591	013	0	1	02	01	H5591_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	28						600.00	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5591	015	1	1	02	01	H5591_015_1	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	1	1	02	01	H5591_015_1	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	1	1	02	01	H5591_015_1	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	015	1	1	02	01	H5591_015_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	1	1	02	01	H5591_015_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	015	1	1	02	01	H5591_015_1	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	1	1	02	01	H5591_015_1	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.15	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5591	015	2	1	02	01	H5591_015_2	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					4.00	8.00	10.00																4.00				4.00			0.13	0.00	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	2	1	02	01	H5591_015_2	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								18.00	36.00	54.00					10.00	20.00	30.00					18.00	36.00	45.00																18.00				18.00			0.60	0.33	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	2	1	02	01	H5591_015_2	6			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					47.00	94.00	117.50																47.00				47.00			1.57	1.33	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5591	015	2	1	02	01	H5591_015_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					100.00	200.00	250.00																100.00				100.00			3.33	3.17	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	2	1	02	01	H5591_015_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											600.00	33						600.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00						35.00		35.00
H5591	015	2	1	02	01	H5591_015_2	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								4.00	8.00	12.00					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5591	015	2	1	02	01	H5591_015_2	6			Select Care Drugs	4	01	1	1	6	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31											1.15	15	15	15				0.00	0	0	0				0	0	0															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5594	001	0	1	01	01	H5594_001_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	001	0	1	01	01	H5594_001_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	001	0	1	01	01	H5594_001_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5594	001	0	1	01	01	H5594_001_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	70.00		210.00																			70.00		140.00																70.00				70.00		2.33			2.33			2.06	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	001	0	1	01	01	H5594_001_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	002	0	1	01	01	H5594_002_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	002	0	1	01	01	H5594_002_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	002	0	1	01	01	H5594_002_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	5.00		15.00																			5.00		10.00																5.00				5.00		0.17			0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				5.00		10.00				5		5
H5594	002	0	1	01	01	H5594_002_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	50.00		150.00																			50.00		100.00																50.00				50.00		1.67			1.67			1.47	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	002	0	1	01	01	H5594_002_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	016	0	1	01	01	H5594_016_0	8		N	Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	15.00		45.00																			15.00		45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		45.00				15.00		15.00
H5594	016	0	1	01	01	H5594_016_0	8		N	Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	45.00		135.00																			45.00		135.00																45.00				45.00		1.50			1.50			1.32	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H5594	016	0	1	01	01	H5594_016_0	8		N	Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	95.00		285.00																			95.00		285.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	016	0	1	01	01	H5594_016_0	8		N	Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	017	0	1	01	01	H5594_017_0	8		N	Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	15.00		45.00																			15.00		45.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		45.00				15.00		15.00
H5594	017	0	1	01	01	H5594_017_0	8		N	Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	45.00		135.00																			45.00		135.00																45.00				45.00		1.50			1.50			1.32	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H5594	017	0	1	01	01	H5594_017_0	8		N	Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	95.00		285.00																			95.00		285.00																95.00				95.00		3.17			3.17			2.79	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	017	0	1	01	01	H5594_017_0	8		N	Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					25																				25																	25			25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	019	0	1	01	01	H5594_019_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	019	0	1	01	01	H5594_019_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	019	0	1	01	01	H5594_019_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	019	0	1	01	01	H5594_019_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	019	0	1	01	01	H5594_019_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	022	0	1	01	01	H5594_022_0	7			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	022	0	1	01	01	H5594_022_0	7			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	022	0	1	01	01	H5594_022_0	7			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	022	0	1	01	01	H5594_022_0	7			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	022	0	1	01	01	H5594_022_0	7			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	026	0	1	01	01	H5594_026_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	026	0	1	01	01	H5594_026_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	026	0	1	01	01	H5594_026_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	026	0	1	01	01	H5594_026_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	026	0	1	01	01	H5594_026_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	028	0	1	01	01	H5594_028_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5594	028	0	1	01	01	H5594_028_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5594	028	0	1	01	01	H5594_028_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													15.00		45.00				15.00		30.00				15		15
H5594	028	0	1	01	01	H5594_028_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	55.00		165.00																			55.00		110.00																55.00				55.00		1.83			1.83			1.62	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35		35
H5594	028	0	1	01	01	H5594_028_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5594	028	0	1	01	01	H5594_028_0	6			Select Diabetic Drugs	4	10	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		30.00				10.00		20.00				10		10
H5594	028	0	1	01	01	H5594_028_0	6			Select Diabetic Drugs	4	10	1	2	5	3	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H5594	029	0	1	01	01	H5594_029_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	029	0	1	01	01	H5594_029_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	029	0	1	01	01	H5594_029_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.44	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		30.00				15		15
H5594	029	0	1	01	01	H5594_029_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	55.00		165.00																			55.00		110.00																55.00				55.00		1.83			1.83			1.62	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	029	0	1	01	01	H5594_029_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	030	0	1	01	01	H5594_030_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5594	030	0	1	01	01	H5594_030_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5594	030	0	1	01	01	H5594_030_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													30.00		90.00				30.00		60.00				30		30
H5594	030	0	1	01	01	H5594_030_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	80.00		240.00																			80.00		160.00																80.00				80.00		2.67			2.67			2.35	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35		35
H5594	030	0	1	01	01	H5594_030_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5594	030	0	1	01	01	H5594_030_0	6			Select Diabetic Drugs	4	11	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.29	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		30.00				10.00		20.00				10		10
H5594	031	0	1	01	01	H5594_031_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	031	0	1	01	01	H5594_031_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	031	0	1	01	01	H5594_031_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	30.00		90.00																			30.00		60.00																30.00				30.00		1.00			1.00			0.88	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				30.00		60.00				30		30
H5594	031	0	1	01	01	H5594_031_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	80.00		240.00																			80.00		160.00																80.00				80.00		2.67			2.67			2.35	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	031	0	1	01	01	H5594_031_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	032	0	1	01	01	H5594_032_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	032	0	1	01	01	H5594_032_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5594	032	0	1	01	01	H5594_032_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	20.00		60.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.59	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		40.00				20		20
H5594	032	0	1	01	01	H5594_032_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	60.00		180.00																			60.00		120.00																60.00				60.00		2.00			2.00			1.76	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	032	0	1	01	01	H5594_032_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	034	0	1	01	01	H5594_034_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	034	0	1	01	01	H5594_034_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	034	0	1	01	01	H5594_034_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	034	0	1	01	01	H5594_034_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	035	0	1	01	01	H5594_035_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H5594	035	0	1	01	01	H5594_035_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.03	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	035	0	1	01	01	H5594_035_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	85.00		255.00																			85.00		170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35		35
H5594	035	0	1	01	01	H5594_035_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5594	036	0	1	01	01	H5594_036_0	6			Preferred Generic	4	11	3	2	1	1	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5594	036	0	1	01	01	H5594_036_0	6			Preferred Generic	4	11	3	2	1	3	110		01	110		1	30		100				2	2	30		100				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1		3															
H5594	036	0	1	01	01	H5594_036_0	6			Preferred Brand	4	11	3	2	2	1	110		01	110		1	30		90				2	2	30		90				30		34	5.00		15.00																			5.00		10.00																5.00				5.00		0.17			0.17			0.15	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													5.00		15.00				5.00		10.00				5		5
H5594	036	0	1	01	01	H5594_036_0	6			Non-Preferred Drug	4	11	3	2	3	1	110		01	110		1	30		90				2	2	30		90				30		34	50.00		150.00																			50.00		100.00																50.00				50.00		1.67			1.67			1.47	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		105.00				35.00		70.00				35		35
H5594	036	0	1	01	01	H5594_036_0	6			Specialty Tier	4	11	1	1	4	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																											
H5594	036	0	1	01	01	H5594_036_0	6			Select Diabetic Drugs	4	11	1	2	5	1	110		01	110		1	30		90				1	2	30		90				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00				0.00		0.00				0.00		0.00
H5594	036	0	1	01	01	H5594_036_0	6			Select Diabetic Drugs	4	11	1	2	5	3	110		01	110		1	30		90				1	2	30		90				30		34	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H5599	002	0	1	02	01	H5599_002_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5599	002	0	1	02	01	H5599_002_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5599	002	0	1	02	01	H5599_002_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H5599	002	0	1	02	01	H5599_002_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.08	50	50	50				87.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5599	002	0	1	02	01	H5599_002_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5599	002	0	1	02	01	H5599_002_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5599	004	0	1	01	01	H5599_004_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5599	004	0	1	01	01	H5599_004_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5599	004	0	1	01	01	H5599_004_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5599	004	0	1	01	01	H5599_004_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.95	50	50	50				84.95	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5599	004	0	1	01	01	H5599_004_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5599	004	0	1	01	01	H5599_004_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5608	002	0	1	01	01	H5608_002_0	9			Preferred Generic	4	01	1	2	1	1	111		10	100		1	30	60	100				1	2			100					10	31	0.00	0.00	0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5608	002	0	1	01	01	H5608_002_0	9			Generic	4	01	1	2	2	1	111		10	100		1	30	60	100				1	2			100					10	31	9.00	18.00	18.00																					0.00																	9.00			9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00	18.00	18.00						0.00				9.00		9.00
H5608	002	0	1	01	01	H5608_002_0	9			Preferred Brand	4	10	1	2	3	1	111		10	100		1	30	60	100				1	2			100					10	31	47.00	94.00	141.00																					141.00																	47.00			47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5608	002	0	1	01	01	H5608_002_0	9			Non-Preferred Brand	4	10	1	2	4	1	111		10	100		1	30	60	100				1	2			100					10	31	95.00	190.00	285.00																					285.00																	95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5608	002	0	1	01	01	H5608_002_0	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				306.31	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5608	002	0	1	01	01	H5608_002_0	9			Select Care Drugs	4	01	1	2	6	1	111		10	100		1	30	60	100				1	2			100					10	31	0.00	0.00	0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5619	001	0	1	01	01	H5619_001_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	001	0	1	01	01	H5619_001_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	001	0	1	01	01	H5619_001_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	001	0	1	01	01	H5619_001_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	001	0	1	01	01	H5619_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	001	0	1	01	01	H5619_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	001	0	1	01	01	H5619_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	012	0	1	01	01	H5619_012_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	012	0	1	01	01	H5619_012_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	012	0	1	01	01	H5619_012_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	012	0	1	01	01	H5619_012_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	012	0	1	01	01	H5619_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	015	0	1	01	01	H5619_015_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	015	0	1	01	01	H5619_015_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5619	015	0	1	01	01	H5619_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	015	0	1	01	01	H5619_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	015	0	1	01	01	H5619_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	016	0	1	01	01	H5619_016_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	016	0	1	01	01	H5619_016_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	016	0	1	01	01	H5619_016_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	016	0	1	01	01	H5619_016_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	016	0	1	01	01	H5619_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	021	0	1	01	01	H5619_021_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	021	0	1	01	01	H5619_021_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	021	0	1	01	01	H5619_021_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	021	0	1	01	01	H5619_021_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	021	0	1	01	01	H5619_021_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	35.00		105.00																									47.00		141.00				35.00		70.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00
H5619	021	0	1	01	01	H5619_021_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	021	0	1	01	01	H5619_021_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	026	0	1	01	01	H5619_026_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5619	026	0	1	01	01	H5619_026_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5619	026	0	1	01	01	H5619_026_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	026	0	1	01	01	H5619_026_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	026	0	1	01	01	H5619_026_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	029	0	1	01	01	H5619_029_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H5619	029	0	1	01	01	H5619_029_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5619	029	0	1	01	01	H5619_029_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	029	0	1	01	01	H5619_029_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	029	0	1	01	01	H5619_029_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	032	0	1	01	01	H5619_032_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	032	0	1	01	01	H5619_032_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5619	032	0	1	01	01	H5619_032_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	032	0	1	01	01	H5619_032_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	032	0	1	01	01	H5619_032_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	039	1	1	01	01	H5619_039_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	039	1	1	01	01	H5619_039_1	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	039	1	1	01	01	H5619_039_1	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	039	1	1	01	01	H5619_039_1	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	039	1	1	01	01	H5619_039_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	039	1	1	01	01	H5619_039_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	039	1	1	01	01	H5619_039_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	039	2	1	01	01	H5619_039_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	039	2	1	01	01	H5619_039_2	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	039	2	1	01	01	H5619_039_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	039	2	1	01	01	H5619_039_2	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	039	2	1	01	01	H5619_039_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	039	2	1	01	01	H5619_039_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	039	2	1	01	01	H5619_039_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	046	0	1	01	01	H5619_046_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	046	0	1	01	01	H5619_046_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	046	0	1	01	01	H5619_046_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	046	0	1	01	01	H5619_046_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	046	0	1	01	01	H5619_046_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5619	046	0	1	01	01	H5619_046_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5619	047	0	1	01	01	H5619_047_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	047	0	1	01	01	H5619_047_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	047	0	1	01	01	H5619_047_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	047	0	1	01	01	H5619_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	047	0	1	01	01	H5619_047_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	049	0	1	02	01	H5619_049_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	049	0	1	02	01	H5619_049_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	049	0	1	02	01	H5619_049_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	049	0	1	02	01	H5619_049_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	049	0	1	02	01	H5619_049_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	049	0	1	02	01	H5619_049_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	049	0	1	02	01	H5619_049_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	051	0	1	02	01	H5619_051_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	051	0	1	02	01	H5619_051_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	051	0	1	02	01	H5619_051_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	051	0	1	02	01	H5619_051_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	051	0	1	02	01	H5619_051_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	051	0	1	02	01	H5619_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	051	0	1	02	01	H5619_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	053	0	1	02	01	H5619_053_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	053	0	1	02	01	H5619_053_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	053	0	1	02	01	H5619_053_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	053	0	1	02	01	H5619_053_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	053	0	1	02	01	H5619_053_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	053	0	1	02	01	H5619_053_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	053	0	1	02	01	H5619_053_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	055	0	1	01	01	H5619_055_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H5619	055	0	1	01	01	H5619_055_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H5619	055	0	1	01	01	H5619_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	055	0	1	01	01	H5619_055_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	055	0	1	01	01	H5619_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5619	055	0	1	01	01	H5619_055_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									11.00		33.00				7.00		0.00				7.00				7.00		0.23				0.37	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00		21.00				11.00		33.00	7.00		0.00	7.00		7.00
H5619	056	0	1	01	01	H5619_056_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	056	0	1	01	01	H5619_056_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	056	0	1	01	01	H5619_056_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5619	056	0	1	01	01	H5619_056_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	056	0	1	01	01	H5619_056_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	056	0	1	01	01	H5619_056_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	056	0	1	01	01	H5619_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	057	0	1	01	01	H5619_057_0	8			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	057	0	1	01	01	H5619_057_0	8			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	057	0	1	01	01	H5619_057_0	8			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	057	0	1	01	01	H5619_057_0	8			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	057	0	1	01	01	H5619_057_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	057	0	1	01	01	H5619_057_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	057	0	1	01	01	H5619_057_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	059	0	1	01	01	H5619_059_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	059	0	1	01	01	H5619_059_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	059	0	1	01	01	H5619_059_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	059	0	1	01	01	H5619_059_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	059	0	1	01	01	H5619_059_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	059	0	1	01	01	H5619_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	059	0	1	01	01	H5619_059_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	060	0	1	01	01	H5619_060_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	060	0	1	01	01	H5619_060_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	060	0	1	01	01	H5619_060_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5619	060	0	1	01	01	H5619_060_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	060	0	1	01	01	H5619_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	060	0	1	01	01	H5619_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	060	0	1	01	01	H5619_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	061	0	1	01	01	H5619_061_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	061	0	1	01	01	H5619_061_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	061	0	1	01	01	H5619_061_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	061	0	1	01	01	H5619_061_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	061	0	1	01	01	H5619_061_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	061	0	1	01	01	H5619_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	061	0	1	01	01	H5619_061_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	063	0	1	01	01	H5619_063_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	063	0	1	01	01	H5619_063_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	063	0	1	01	01	H5619_063_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H5619	063	0	1	01	01	H5619_063_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	063	0	1	01	01	H5619_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	063	0	1	01	01	H5619_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	063	0	1	01	01	H5619_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	065	0	1	01	01	H5619_065_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									19.00		57.00				0.00		0.00				0.00				0.00		0.00				0.63	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				19.00		57.00	0.00		0.00	0.00		0.00
H5619	065	0	1	01	01	H5619_065_0	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									19.00		57.00				0.00		0.00				0.00				0.00		0.00				0.63	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	065	0	1	01	01	H5619_065_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	065	0	1	01	01	H5619_065_0	8			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	065	0	1	01	01	H5619_065_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	065	0	1	01	01	H5619_065_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	065	0	1	01	01	H5619_065_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	066	0	1	01	01	H5619_066_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	066	0	1	01	01	H5619_066_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	066	0	1	01	01	H5619_066_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	066	0	1	01	01	H5619_066_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	066	0	1	01	01	H5619_066_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	066	0	1	01	01	H5619_066_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	066	0	1	01	01	H5619_066_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	069	0	1	02	01	H5619_069_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5619	069	0	1	02	01	H5619_069_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	11.00		33.00																									20.00		60.00				11.00		0.00				11.00				11.00		0.37				0.67	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00		33.00				20.00		60.00	11.00		0.00	11.00		11.00
H5619	069	0	1	02	01	H5619_069_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	069	0	1	02	01	H5619_069_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	069	0	1	02	01	H5619_069_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	071	0	1	01	01	H5619_071_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	071	0	1	01	01	H5619_071_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	071	0	1	01	01	H5619_071_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	071	0	1	01	01	H5619_071_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	071	0	1	01	01	H5619_071_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	071	0	1	01	01	H5619_071_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	071	0	1	01	01	H5619_071_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	077	0	1	01	01	H5619_077_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	077	0	1	01	01	H5619_077_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	077	0	1	01	01	H5619_077_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5619	077	0	1	01	01	H5619_077_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	077	0	1	01	01	H5619_077_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	077	0	1	01	01	H5619_077_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	077	0	1	01	01	H5619_077_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	083	0	1	01	01	H5619_083_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
H5619	083	0	1	01	01	H5619_083_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H5619	083	0	1	01	01	H5619_083_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	083	0	1	01	01	H5619_083_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	083	0	1	01	01	H5619_083_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	089	0	1	01	01	H5619_089_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	089	0	1	01	01	H5619_089_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	089	0	1	01	01	H5619_089_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	089	0	1	01	01	H5619_089_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	089	0	1	01	01	H5619_089_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	090	0	1	01	01	H5619_090_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	090	0	1	01	01	H5619_090_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	090	0	1	01	01	H5619_090_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	090	0	1	01	01	H5619_090_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	090	0	1	01	01	H5619_090_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	091	0	1	01	01	H5619_091_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	091	0	1	01	01	H5619_091_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	091	0	1	01	01	H5619_091_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	091	0	1	01	01	H5619_091_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	091	0	1	01	01	H5619_091_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	095	0	1	01	01	H5619_095_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	095	0	1	01	01	H5619_095_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	095	0	1	01	01	H5619_095_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	095	0	1	01	01	H5619_095_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	095	0	1	01	01	H5619_095_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	100	0	1	01	01	H5619_100_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	100	0	1	01	01	H5619_100_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	100	0	1	01	01	H5619_100_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5619	100	0	1	01	01	H5619_100_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	100	0	1	01	01	H5619_100_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	100	0	1	01	01	H5619_100_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	100	0	1	01	01	H5619_100_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	111	0	1	02	01	H5619_111_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	111	0	1	02	01	H5619_111_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	111	0	1	02	01	H5619_111_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	111	0	1	02	01	H5619_111_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	111	0	1	02	01	H5619_111_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	111	0	1	02	01	H5619_111_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	111	0	1	02	01	H5619_111_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	113	0	1	02	01	H5619_113_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	113	0	1	02	01	H5619_113_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	113	0	1	02	01	H5619_113_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	113	0	1	02	01	H5619_113_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	113	0	1	02	01	H5619_113_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	113	0	1	02	01	H5619_113_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	113	0	1	02	01	H5619_113_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	114	0	1	01	01	H5619_114_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	114	0	1	01	01	H5619_114_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5619	114	0	1	01	01	H5619_114_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	114	0	1	01	01	H5619_114_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	114	0	1	01	01	H5619_114_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	116	0	1	01	01	H5619_116_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	116	0	1	01	01	H5619_116_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5619	116	0	1	01	01	H5619_116_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	116	0	1	01	01	H5619_116_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	116	0	1	01	01	H5619_116_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	119	0	1	01	01	H5619_119_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	119	0	1	01	01	H5619_119_0	4			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	119	0	1	01	01	H5619_119_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	119	0	1	01	01	H5619_119_0	4			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	119	0	1	01	01	H5619_119_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	119	0	1	01	01	H5619_119_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	119	0	1	01	01	H5619_119_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	122	0	1	01	01	H5619_122_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H5619	122	0	1	01	01	H5619_122_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	11.00		33.00																									20.00		60.00				11.00		0.00				11.00				11.00		0.37				0.67	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00		33.00				20.00		60.00	11.00		0.00	11.00		11.00
H5619	122	0	1	01	01	H5619_122_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	122	0	1	01	01	H5619_122_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	122	0	1	01	01	H5619_122_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	128	0	1	01	01	H5619_128_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	128	0	1	01	01	H5619_128_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	128	0	1	01	01	H5619_128_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	128	0	1	01	01	H5619_128_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	128	0	1	01	01	H5619_128_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	128	0	1	01	01	H5619_128_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	128	0	1	01	01	H5619_128_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	130	1	1	01	01	H5619_130_1	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	130	1	1	01	01	H5619_130_1	6			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	130	1	1	01	01	H5619_130_1	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	130	1	1	01	01	H5619_130_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	130	1	1	01	01	H5619_130_1	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	130	2	1	01	01	H5619_130_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	130	2	1	01	01	H5619_130_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	130	2	1	01	01	H5619_130_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	130	2	1	01	01	H5619_130_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	130	2	1	01	01	H5619_130_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	131	0	1	01	01	H5619_131_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	131	0	1	01	01	H5619_131_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	131	0	1	01	01	H5619_131_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	131	0	1	01	01	H5619_131_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	131	0	1	01	01	H5619_131_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	133	0	1	01	01	H5619_133_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	133	0	1	01	01	H5619_133_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	133	0	1	01	01	H5619_133_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	133	0	1	01	01	H5619_133_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	133	0	1	01	01	H5619_133_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	133	0	1	01	01	H5619_133_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	133	0	1	01	01	H5619_133_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	135	0	1	01	01	H5619_135_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5619	135	0	1	01	01	H5619_135_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5619	135	0	1	01	01	H5619_135_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	135	0	1	01	01	H5619_135_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	135	0	1	01	01	H5619_135_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	137	0	1	01	01	H5619_137_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	137	0	1	01	01	H5619_137_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	137	0	1	01	01	H5619_137_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	137	0	1	01	01	H5619_137_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	137	0	1	01	01	H5619_137_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	137	0	1	01	01	H5619_137_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	137	0	1	01	01	H5619_137_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	138	0	1	01	01	H5619_138_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	138	0	1	01	01	H5619_138_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H5619	138	0	1	01	01	H5619_138_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	138	0	1	01	01	H5619_138_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	138	0	1	01	01	H5619_138_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	143	0	1	01	01	H5619_143_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	143	0	1	01	01	H5619_143_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	143	0	1	01	01	H5619_143_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	143	0	1	01	01	H5619_143_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	143	0	1	01	01	H5619_143_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	143	0	1	01	01	H5619_143_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	143	0	1	01	01	H5619_143_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	145	0	1	01	01	H5619_145_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	10.00		30.00																									19.00		57.00				10.00		0.00				10.00				10.00		0.33				0.63	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				19.00		57.00	10.00		0.00	10.00		10.00
H5619	145	0	1	01	01	H5619_145_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H5619	145	0	1	01	01	H5619_145_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	145	0	1	01	01	H5619_145_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	145	0	1	01	01	H5619_145_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	146	0	1	01	01	H5619_146_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	146	0	1	01	01	H5619_146_0	4			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	146	0	1	01	01	H5619_146_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	146	0	1	01	01	H5619_146_0	4			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	146	0	1	01	01	H5619_146_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	146	0	1	01	01	H5619_146_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	146	0	1	01	01	H5619_146_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	147	0	1	01	01	H5619_147_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	147	0	1	01	01	H5619_147_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	147	0	1	01	01	H5619_147_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	147	0	1	01	01	H5619_147_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	147	0	1	01	01	H5619_147_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	148	0	1	01	01	H5619_148_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	148	0	1	01	01	H5619_148_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5619	148	0	1	01	01	H5619_148_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	148	0	1	01	01	H5619_148_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	148	0	1	01	01	H5619_148_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	150	0	1	01	01	H5619_150_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	150	0	1	01	01	H5619_150_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	150	0	1	01	01	H5619_150_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	150	0	1	01	01	H5619_150_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	150	0	1	01	01	H5619_150_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	152	0	1	01	01	H5619_152_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	152	0	1	01	01	H5619_152_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	152	0	1	01	01	H5619_152_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	152	0	1	01	01	H5619_152_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	152	0	1	01	01	H5619_152_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	152	0	1	01	01	H5619_152_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	152	0	1	01	01	H5619_152_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	154	0	1	01	01	H5619_154_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	154	0	1	01	01	H5619_154_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5619	154	0	1	01	01	H5619_154_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	154	0	1	01	01	H5619_154_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5619	154	0	1	01	01	H5619_154_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	154	0	1	01	01	H5619_154_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	154	0	1	01	01	H5619_154_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	157	0	1	01	01	H5619_157_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	157	0	1	01	01	H5619_157_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	157	0	1	01	01	H5619_157_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	157	0	1	01	01	H5619_157_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	157	0	1	01	01	H5619_157_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	159	0	1	01	01	H5619_159_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	159	0	1	01	01	H5619_159_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H5619	159	0	1	01	01	H5619_159_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		94.00	35.00		35.00
H5619	159	0	1	01	01	H5619_159_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	159	0	1	01	01	H5619_159_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5619	161	0	1	01	01	H5619_161_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5619	161	0	1	01	01	H5619_161_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5619	161	0	1	01	01	H5619_161_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5619	161	0	1	01	01	H5619_161_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5619	161	0	1	01	01	H5619_161_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5619	161	0	1	01	01	H5619_161_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5619	161	0	1	01	01	H5619_161_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00						0.00			0.00			0.00		0.00
H5619	161	0	1	01	01	H5619_161_0	6			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H5619	164	0	1	01	01	H5619_164_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5619	164	0	1	01	01	H5619_164_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5619	164	0	1	01	01	H5619_164_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5619	164	0	1	01	01	H5619_164_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5619	164	0	1	01	01	H5619_164_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	164	0	1	01	01	H5619_164_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5619	164	0	1	01	01	H5619_164_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H5619	164	0	1	01	01	H5619_164_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									11.00		33.00				0.00		0.00				0.00				0.00		0.00				0.37	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				11.00		33.00	0.00		0.00	0.00		0.00
H5628	007	0	1	01	01	H5628_007_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	2.00	4.00	6.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	007	0	1	01	01	H5628_007_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	8.00	16.00	24.00																			8.00	16.00	16.00																8.00				8.00		0.26			0.26			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	007	0	1	01	01	H5628_007_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.45			1.45			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00
H5628	007	0	1	01	01	H5628_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	007	0	1	01	01	H5628_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1024.71	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5628	007	0	1	01	01	H5628_007_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	010	0	1	01	01	H5628_010_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	010	0	1	01	01	H5628_010_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	6.00	12.00	18.00																			6.00	12.00	12.00																6.00				6.00		0.19			0.19			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	010	0	1	01	01	H5628_010_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.45			1.45			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00
H5628	010	0	1	01	01	H5628_010_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5628	010	0	1	01	01	H5628_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1149.08	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5628	010	0	1	01	01	H5628_010_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	001	0	1	01	01	H5649_001_0	7			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	001	0	1	01	01	H5649_001_0	7			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	001	0	1	01	01	H5649_001_0	7			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	001	0	1	01	01	H5649_001_0	7			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	001	0	1	01	01	H5649_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	001	0	1	01	01	H5649_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	001	0	1	01	01	H5649_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				102.76	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	001	0	1	01	01	H5649_001_0	7			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	001	0	1	01	01	H5649_001_0	7			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	002	0	1	01	01	H5649_002_0	7		N	Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	002	0	1	01	01	H5649_002_0	7		N	Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	002	0	1	01	01	H5649_002_0	7		N	Generic	4	11	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				4.79	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	002	0	1	01	01	H5649_002_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				86.74	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	002	0	1	01	01	H5649_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				43.38	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	002	0	1	01	01	H5649_002_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				92.53	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	002	0	1	01	01	H5649_002_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	002	0	1	01	01	H5649_002_0	7		N	Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	006	0	1	01	01	H5649_006_0	7			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	006	0	1	01	01	H5649_006_0	7			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	006	0	1	01	01	H5649_006_0	7			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	006	0	1	01	01	H5649_006_0	7			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	006	0	1	01	01	H5649_006_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5649	006	0	1	01	01	H5649_006_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	006	0	1	01	01	H5649_006_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				66.20	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	006	0	1	01	01	H5649_006_0	7			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	006	0	1	01	01	H5649_006_0	7			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	008	0	1	01	01	H5649_008_0	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	008	0	1	01	01	H5649_008_0	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	008	0	1	01	01	H5649_008_0	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	008	0	1	01	01	H5649_008_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	008	0	1	01	01	H5649_008_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	008	0	1	01	01	H5649_008_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				113.34	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	008	0	1	01	01	H5649_008_0	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	008	0	1	01	01	H5649_008_0	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	009	0	1	01	01	H5649_009_0	7		N	Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	009	0	1	01	01	H5649_009_0	7		N	Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	009	0	1	01	01	H5649_009_0	7		N	Generic	4	11	1	1	2	1	111		01	100		1	30	60	100				2	2			100				30		31				4.75	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	009	0	1	01	01	H5649_009_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				89.81	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	009	0	1	01	01	H5649_009_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				43.86	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	009	0	1	01	01	H5649_009_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				108.31	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	009	0	1	01	01	H5649_009_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	009	0	1	01	01	H5649_009_0	7		N	Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	018	0	1	01	01	H5649_018_0	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	018	0	1	01	01	H5649_018_0	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	018	0	1	01	01	H5649_018_0	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	018	0	1	01	01	H5649_018_0	8			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	018	0	1	01	01	H5649_018_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	018	0	1	01	01	H5649_018_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	018	0	1	01	01	H5649_018_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				108.54	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	018	0	1	01	01	H5649_018_0	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	018	0	1	01	01	H5649_018_0	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	019	0	1	01	01	H5649_019_0	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	019	0	1	01	01	H5649_019_0	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	019	0	1	01	01	H5649_019_0	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	019	0	1	01	01	H5649_019_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	47.00	94.00	94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	019	0	1	01	01	H5649_019_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	100.00	200.00	200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	019	0	1	01	01	H5649_019_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.16	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	019	0	1	01	01	H5649_019_0	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	019	0	1	01	01	H5649_019_0	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	020	1	1	01	01	H5649_020_1	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	1	1	01	01	H5649_020_1	9			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	020	1	1	01	01	H5649_020_1	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	1	1	01	01	H5649_020_1	9			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	020	1	1	01	01	H5649_020_1	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	020	1	1	01	01	H5649_020_1	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	1	1	01	01	H5649_020_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				102.24	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	1	1	01	01	H5649_020_1	9			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	1	1	01	01	H5649_020_1	9			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	020	2	1	01	01	H5649_020_2	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	2	1	01	01	H5649_020_2	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	020	2	1	01	01	H5649_020_2	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	2	1	01	01	H5649_020_2	8			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	020	2	1	01	01	H5649_020_2	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	020	2	1	01	01	H5649_020_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	2	1	01	01	H5649_020_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				102.24	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	2	1	01	01	H5649_020_2	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	020	2	1	01	01	H5649_020_2	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	021	1	1	01	01	H5649_021_1	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	1	1	01	01	H5649_021_1	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	021	1	1	01	01	H5649_021_1	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	1	1	01	01	H5649_021_1	8			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	021	1	1	01	01	H5649_021_1	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	021	1	1	01	01	H5649_021_1	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	1	1	01	01	H5649_021_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				107.24	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	1	1	01	01	H5649_021_1	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	1	1	01	01	H5649_021_1	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5649	021	2	1	01	01	H5649_021_2	8			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	2	1	01	01	H5649_021_2	8			Preferred Generic	4	11	1	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	021	2	1	01	01	H5649_021_2	8			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	2	1	01	01	H5649_021_2	8			Generic	4	11	1	2	2	3	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5649	021	2	1	01	01	H5649_021_2	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				2	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5649	021	2	1	01	01	H5649_021_2	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				2	2			100				30		31	75.00	150.00	150.00																					150.00																75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	2	1	01	01	H5649_021_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				107.24	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	2	1	01	01	H5649_021_2	8			Select Care Drugs	4	11	3	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5649	021	2	1	01	01	H5649_021_2	8			Select Care Drugs	4	11	3	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5652	001	0	1	02	01	H5652_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	001	0	1	02	01	H5652_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5652	001	0	1	02	01	H5652_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	001	0	1	02	01	H5652_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5652	001	0	1	02	01	H5652_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	001	0	1	02	01	H5652_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	85.00		255.00																											255.00						245.00				85.00				85.00		2.83						2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	001	0	1	02	01	H5652_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	003	0	1	02	01	H5652_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	003	0	1	02	01	H5652_003_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5652	003	0	1	02	01	H5652_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	003	0	1	02	01	H5652_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5652	003	0	1	02	01	H5652_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	28.00		84.00																											84.00						74.00				28.00				28.00		0.93						0.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													28.00		84.00						84.00			74.00	28.00		28.00
H5652	003	0	1	02	01	H5652_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	70.00		210.00																											210.00						200.00				70.00				70.00		2.33						2.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	003	0	1	02	01	H5652_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	004	0	1	02	01	H5652_004_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	004	0	1	02	01	H5652_004_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5652	004	0	1	02	01	H5652_004_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	004	0	1	02	01	H5652_004_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5652	004	0	1	02	01	H5652_004_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
H5652	004	0	1	02	01	H5652_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	85.00		255.00																											255.00						245.00				85.00				85.00		2.83						2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	004	0	1	02	01	H5652_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				345.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	006	0	1	02	01	H5652_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	006	0	1	02	01	H5652_006_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5652	006	0	1	02	01	H5652_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	006	0	1	02	01	H5652_006_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5652	006	0	1	02	01	H5652_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	006	0	1	02	01	H5652_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	85.00		255.00																											255.00						245.00				85.00				85.00		2.83						2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	006	0	1	02	01	H5652_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				227.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	008	0	1	02	01	H5652_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	008	0	1	02	01	H5652_008_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5652	008	0	1	02	01	H5652_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	15.00		45.00																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5652	008	0	1	02	01	H5652_008_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	15.00		45.00																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H5652	008	0	1	02	01	H5652_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	008	0	1	02	01	H5652_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H5652	008	0	1	02	01	H5652_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				545.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5774	005	0	1	01	01	H5774_005_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	005	0	1	01	01	H5774_005_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	005	0	1	01	01	H5774_005_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	005	0	1	01	01	H5774_005_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	005	0	1	01	01	H5774_005_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								30.00		60.00					0.00		0.00							0.00																30.00				0.00			1.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	005	0	1	01	01	H5774_005_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					5.00		10.00							10.00																55.00				5.00			1.83	0.17				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	005	0	1	01	01	H5774_005_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	005	0	1	01	01	H5774_005_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H5774	005	0	1	01	01	H5774_005_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5774	022	0	1	01	01	H5774_022_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	022	0	1	01	01	H5774_022_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	022	0	1	01	01	H5774_022_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	022	0	1	01	01	H5774_022_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	022	0	1	01	01	H5774_022_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					0.00		0.00							0.00																20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	022	0	1	01	01	H5774_022_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	022	0	1	01	01	H5774_022_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	022	0	1	01	01	H5774_022_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H5774	022	0	1	01	01	H5774_022_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5774	024	0	1	01	01	H5774_024_0	5		N	Preferred Generic	2	01	1	2	1	1		110	01	100		1				30		90	1	2			90				30		31								19.00		38.00					16.00		32.00							32.00																19.00				16.00			0.63	0.53				0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	024	0	1	01	01	H5774_024_0	5		N	Generic	2	01	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					17.00		34.00							34.00																20.00				17.00			0.67	0.57				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	024	0	1	01	01	H5774_024_0	5		N	Preferred Brand	2	10	1	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		94.00					42.00		84.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	024	0	1	01	01	H5774_024_0	5		N	Non-Preferred Brand	2	10	1	2	4	1		110	01	100		1				30		90	1	1			90				30		31								100.00		200.00					95.00		190.00							190.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	024	0	1	01	01	H5774_024_0	5		N	Specialty Tier	2	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												25		25					25		25						25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	024	0	1	01	01	H5774_024_0	5		N	Select Care Drugs	2	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								9.00		18.00					8.00		16.00							16.00																9.00				8.00			0.30	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00		18.00	8.00		16.00			16.00				9.00		8.00
H5774	026	0	1	01	01	H5774_026_0	4		N	Preferred Generic	2	01	1	2	1	1		110	01	100		1				30		90	1	2			90				30		31								19.00		38.00					16.00		32.00							32.00																19.00				16.00			0.63	0.53				0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	026	0	1	01	01	H5774_026_0	4		N	Generic	2	01	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					17.00		34.00							34.00																20.00				17.00			0.67	0.57				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	026	0	1	01	01	H5774_026_0	4		N	Preferred Brand	2	10	1	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		94.00					42.00		84.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	026	0	1	01	01	H5774_026_0	4		N	Non-Preferred Brand	2	10	1	2	4	1		110	01	100		1				30		90	1	1			90				30		31								100.00		200.00					95.00		190.00							190.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	026	0	1	01	01	H5774_026_0	4		N	Specialty Tier	2	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												25		25					25		25						25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	026	0	1	01	01	H5774_026_0	4		N	Select Care Drugs	2	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								9.00		18.00					8.00		16.00							16.00																9.00				8.00			0.30	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00		18.00	8.00		16.00			16.00				9.00		8.00
H5774	027	0	1	02	01	H5774_027_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	027	0	1	02	01	H5774_027_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	027	0	1	02	01	H5774_027_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	027	0	1	02	01	H5774_027_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	027	0	1	02	01	H5774_027_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								30.00		60.00					5.00		10.00							10.00																30.00				5.00			1.00	0.17				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	027	0	1	02	01	H5774_027_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					25.00		50.00							50.00																55.00				25.00			1.83	0.83				0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	027	0	1	02	01	H5774_027_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	027	0	1	02	01	H5774_027_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H5774	027	0	1	02	01	H5774_027_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5774	028	0	1	01	01	H5774_028_0	5		N	Preferred Generic	2	01	1	2	1	1		110	01	100		1				30		90	1	2			90				30		31								19.00		38.00					16.00		32.00							32.00																19.00				16.00			0.63	0.53				0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	028	0	1	01	01	H5774_028_0	5		N	Generic	2	01	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					17.00		34.00							34.00																20.00				17.00			0.67	0.57				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	028	0	1	01	01	H5774_028_0	5		N	Preferred Brand	2	10	1	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		94.00					42.00		84.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	028	0	1	01	01	H5774_028_0	5		N	Non-Preferred Brand	2	10	1	2	4	1		110	01	100		1				30		90	1	1			90				30		31								100.00		200.00					95.00		190.00							190.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	028	0	1	01	01	H5774_028_0	5		N	Specialty Tier	2	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												25		25					25		25						25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	028	0	1	01	01	H5774_028_0	5		N	Select Care Drugs	2	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								9.00		18.00					8.00		16.00							16.00																9.00				8.00			0.30	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00		18.00	8.00		16.00			16.00				9.00		8.00
H5774	031	0	1	02	01	H5774_031_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	031	0	1	02	01	H5774_031_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	031	0	1	02	01	H5774_031_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	031	0	1	02	01	H5774_031_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	031	0	1	02	01	H5774_031_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								35.00		70.00					25.00		50.00							50.00																35.00				25.00			1.17	0.83				0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	031	0	1	02	01	H5774_031_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								45.00		90.00					40.00		80.00							80.00																45.00				40.00			1.50	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	031	0	1	02	01	H5774_031_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												33		33					33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	031	0	1	02	01	H5774_031_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H5774	031	0	1	02	01	H5774_031_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5774	035	0	1	01	01	H5774_035_0	5		N	Preferred Generic	2	01	1	2	1	1		110	01	100		1				30		90	1	2			90				30		31								19.00		38.00					16.00		32.00							32.00																19.00				16.00			0.63	0.53				0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	035	0	1	01	01	H5774_035_0	5		N	Generic	2	01	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					17.00		34.00							34.00																20.00				17.00			0.67	0.57				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	035	0	1	01	01	H5774_035_0	5		N	Preferred Brand	2	10	1	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		94.00					42.00		84.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	035	0	1	01	01	H5774_035_0	5		N	Non-Preferred Brand	2	10	1	2	4	1		110	01	100		1				30		90	1	1			90				30		31								100.00		200.00					95.00		190.00							190.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	035	0	1	01	01	H5774_035_0	5		N	Specialty Tier	2	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												25		25					25		25						25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	035	0	1	01	01	H5774_035_0	5		N	Select Care Drugs	2	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								9.00		18.00					8.00		16.00							16.00																9.00				8.00			0.30	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00		18.00	8.00		16.00			16.00				9.00		8.00
H5774	036	0	1	01	01	H5774_036_0	5		N	Preferred Generic	2	01	1	2	1	1		110	01	100		1				30		90	1	2			90				30		31								19.00		38.00					16.00		32.00							32.00																19.00				16.00			0.63	0.53				0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	036	0	1	01	01	H5774_036_0	5		N	Generic	2	01	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					17.00		34.00							34.00																20.00				17.00			0.67	0.57				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	036	0	1	01	01	H5774_036_0	5		N	Preferred Brand	2	10	1	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		94.00					42.00		84.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	036	0	1	01	01	H5774_036_0	5		N	Non-Preferred Brand	2	10	1	2	4	1		110	01	100		1				30		90	1	1			90				30		31								100.00		200.00					95.00		190.00							190.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	036	0	1	01	01	H5774_036_0	5		N	Specialty Tier	2	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												25		25					25		25						25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	036	0	1	01	01	H5774_036_0	5		N	Select Care Drugs	2	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								9.00		18.00					8.00		16.00							16.00																9.00				8.00			0.30	0.27				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00		18.00	8.00		16.00			16.00				9.00		8.00
H5774	037	0	1	01	01	H5774_037_0	6			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	037	0	1	01	01	H5774_037_0	6			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	037	0	1	01	01	H5774_037_0	6			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	037	0	1	01	01	H5774_037_0	6			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	037	0	1	01	01	H5774_037_0	6			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								30.00		60.00					25.00		50.00							50.00																30.00				25.00			1.00	0.83				0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	037	0	1	01	01	H5774_037_0	6			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					35.00		70.00							70.00																55.00				35.00			1.83	1.17				1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	037	0	1	01	01	H5774_037_0	6			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	037	0	1	01	01	H5774_037_0	6			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H5774	037	0	1	01	01	H5774_037_0	6			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5774	038	0	1	01	01	H5774_038_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	038	0	1	01	01	H5774_038_0	5			Preferred Generic	4	01	3	2	1	3		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	038	0	1	01	01	H5774_038_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	038	0	1	01	01	H5774_038_0	5			Generic	4	01	3	2	2	3		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H5774	038	0	1	01	01	H5774_038_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								30.00		60.00					10.00		20.00							20.00																30.00				10.00			1.00	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	038	0	1	01	01	H5774_038_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					15.00		30.00							30.00																55.00				15.00			1.83	0.50				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	038	0	1	01	01	H5774_038_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	038	0	1	01	01	H5774_038_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													3.00		6.00	0.00		0.00			0.00				3.00		0.00
H5774	038	0	1	01	01	H5774_038_0	5			Select Care Drugs	4	11	1	2	6	3		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5774	040	0	1	01	01	H5774_040_0	4		N	Preferred Generic	2	01	1	2	1	1		110	01	100		1				30		90	1	2			90				30		31								16.00		32.00					11.00		22.00							22.00																16.00				11.00			0.53	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	040	0	1	01	01	H5774_040_0	4		N	Generic	2	01	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								17.00		34.00					12.00		24.00							24.00																17.00				12.00			0.57	0.40				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	040	0	1	01	01	H5774_040_0	4		N	Preferred Brand	2	10	1	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		94.00					42.00		84.00							84.00																47.00				42.00			1.57	1.40				1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	040	0	1	01	01	H5774_040_0	4		N	Non-Preferred Brand	2	10	1	2	4	1		110	01	100		1				30		90	1	1			90				30		31								100.00		200.00					95.00		190.00							190.00																100.00				95.00			3.33	3.17				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	040	0	1	01	01	H5774_040_0	4		N	Specialty Tier	2	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												25		25					25		25						25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5774	040	0	1	01	01	H5774_040_0	4		N	Select Care Drugs	2	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					7.00		14.00							14.00																8.00				7.00			0.27	0.23				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													8.00		16.00	7.00		14.00			14.00				8.00		7.00
H5779	002	0	1	01	01	H5779_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	002	0	1	01	01	H5779_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	002	0	1	01	01	H5779_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5779	002	0	1	01	01	H5779_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.20	46	46	46				98.20	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5779	002	0	1	01	01	H5779_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5779	002	0	1	01	01	H5779_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	007	0	1	01	01	H5779_007_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	007	0	1	01	01	H5779_007_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5779	007	0	1	01	01	H5779_007_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	007	0	1	01	01	H5779_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5779	007	0	1	01	01	H5779_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.55	49	49	49				98.55	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5779	007	0	1	01	01	H5779_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5779	007	0	1	01	01	H5779_007_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	007	0	1	01	01	H5779_007_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H5779	009	0	1	01	01	H5779_009_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	009	0	1	01	01	H5779_009_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5779	009	0	1	01	01	H5779_009_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5779	009	0	1	01	01	H5779_009_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.86	50	50	50				88.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5779	009	0	1	01	01	H5779_009_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5779	009	0	1	01	01	H5779_009_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5793	001	0	1	02	01	H5793_001_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	001	0	1	02	01	H5793_001_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	001	0	1	02	01	H5793_001_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	001	0	1	02	01	H5793_001_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	001	0	1	02	01	H5793_001_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	001	0	1	02	01	H5793_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	001	0	1	02	01	H5793_001_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											909.25	33						714.79	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5793	010	0	1	02	01	H5793_010_0	10			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	010	0	1	02	01	H5793_010_0	10			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	010	0	1	02	01	H5793_010_0	10			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	010	0	1	02	01	H5793_010_0	10			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	010	0	1	02	01	H5793_010_0	10			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	010	0	1	02	01	H5793_010_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	010	0	1	02	01	H5793_010_0	10			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											779.06	33						806.55	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5793	014	0	1	02	01	H5793_014_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	014	0	1	02	01	H5793_014_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	014	0	1	02	01	H5793_014_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	014	0	1	02	01	H5793_014_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	014	0	1	02	01	H5793_014_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	014	0	1	02	01	H5793_014_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	014	0	1	02	01	H5793_014_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											685.15	33						632.04	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5793	015	0	1	01	01	H5793_015_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	015	0	1	01	01	H5793_015_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	015	0	1	01	01	H5793_015_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	015	0	1	01	01	H5793_015_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	015	0	1	01	01	H5793_015_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	015	0	1	01	01	H5793_015_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	015	0	1	01	01	H5793_015_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											717.82	33						653.30	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5793	016	0	1	02	01	H5793_016_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	016	0	1	02	01	H5793_016_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	016	0	1	02	01	H5793_016_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	016	0	1	02	01	H5793_016_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	016	0	1	02	01	H5793_016_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	016	0	1	02	01	H5793_016_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	016	0	1	02	01	H5793_016_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											845.77	33						722.07	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5793	018	0	1	02	01	H5793_018_0	10			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	018	0	1	02	01	H5793_018_0	10			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	018	0	1	02	01	H5793_018_0	10			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	018	0	1	02	01	H5793_018_0	10			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	018	0	1	02	01	H5793_018_0	10			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	018	0	1	02	01	H5793_018_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	018	0	1	02	01	H5793_018_0	10			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											748.08	33						664.05	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5793	019	0	1	02	01	H5793_019_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	019	0	1	02	01	H5793_019_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	019	0	1	02	01	H5793_019_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	019	0	1	02	01	H5793_019_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5793	019	0	1	02	01	H5793_019_0	9			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.30	25	25	25				51.28	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5793	019	0	1	02	01	H5793_019_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.30	50	50	50				65.60	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5793	019	0	1	02	01	H5793_019_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											899.52	33						650.37	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5810	014	0	1	01	01	H5810_014_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	014	0	1	01	01	H5810_014_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	014	0	1	01	01	H5810_014_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H5810	014	0	1	01	01	H5810_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	014	0	1	01	01	H5810_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1113.47	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5810	014	0	1	01	01	H5810_014_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	015	0	1	01	01	H5810_015_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	015	0	1	01	01	H5810_015_0	4			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	20.00	40.00	60.00																			20.00	40.00	40.00																20.00				20.00		0.65			0.65			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	015	0	1	01	01	H5810_015_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H5810	015	0	1	01	01	H5810_015_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5810	015	0	1	01	01	H5810_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				937.97	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5810	015	0	1	01	01	H5810_015_0	4			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	1	1	01	01	H5823_012_1	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	1	1	01	01	H5823_012_1	7			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	1	1	01	01	H5823_012_1	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H5823	012	1	1	01	01	H5823_012_1	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	1	1	01	01	H5823_012_1	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5823	012	1	1	01	01	H5823_012_1	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	2	1	01	01	H5823_012_2	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	2	1	01	01	H5823_012_2	6			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	2	1	01	01	H5823_012_2	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H5823	012	2	1	01	01	H5823_012_2	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5823	012	2	1	01	01	H5823_012_2	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5823	012	2	1	01	01	H5823_012_2	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5826	008	0	1	01	01	H5826_008_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	008	0	1	01	01	H5826_008_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								20.00	40.00	40.00					10.00	20.00	20.00											20.00	40.00	40.00				10.00	20.00	20.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	008	0	1	01	01	H5826_008_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								47.00	94.00	140.00					37.00	74.00	110.00											47.00	94.00	140.00				37.00	74.00	110.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5826	008	0	1	01	01	H5826_008_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31											96.67	50	50	50				92.78	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	008	0	1	01	01	H5826_008_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	009	0	1	01	01	H5826_009_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	009	0	1	01	01	H5826_009_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								20.00	40.00	40.00					10.00	20.00	20.00											20.00	40.00	40.00				10.00	20.00	20.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	009	0	1	01	01	H5826_009_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								47.00	94.00	140.00					37.00	74.00	110.00											47.00	94.00	140.00				37.00	74.00	110.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5826	009	0	1	01	01	H5826_009_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31											72.41	50	50	50				76.38	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	009	0	1	01	01	H5826_009_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	010	0	1	01	01	H5826_010_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	010	0	1	01	01	H5826_010_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								20.00	40.00	40.00					10.00	20.00	20.00											20.00	40.00	40.00				10.00	20.00	20.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	010	0	1	01	01	H5826_010_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								47.00	94.00	140.00					37.00	74.00	110.00											47.00	94.00	140.00				37.00	74.00	110.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5826	010	0	1	01	01	H5826_010_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31											73.23	50	50	50				65.42	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	010	0	1	01	01	H5826_010_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	016	0	1	01	01	H5826_016_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	016	0	1	01	01	H5826_016_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								20.00	40.00	40.00					10.00	20.00	20.00											20.00	40.00	40.00				10.00	20.00	20.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	016	0	1	01	01	H5826_016_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31								47.00	94.00	140.00					37.00	74.00	110.00											47.00	94.00	140.00				37.00	74.00	110.00				47.00				47.00			1.57	1.23		1.57	1.23	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5826	016	0	1	01	01	H5826_016_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	1				30	60	90	30		31											78.08	50	50	50				84.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5826	016	0	1	01	01	H5826_016_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5828	008	0	1	01	01	H5828_008_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	008	0	1	01	01	H5828_008_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	008	0	1	01	01	H5828_008_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	111.00	111.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5828	008	0	1	01	01	H5828_008_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					90.00	180.00	270.00					90.00	270.00	270.00																100.00				100.00			3.33	3.00	3.00			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	008	0	1	01	01	H5828_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	008	0	1	01	01	H5828_008_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	1	1	02	01	H5828_012_1	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	1	1	02	01	H5828_012_1	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5828	012	1	1	02	01	H5828_012_1	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	1	1	02	01	H5828_012_1	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5828	012	1	1	02	01	H5828_012_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	1	1	02	01	H5828_012_1	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	1	1	02	01	H5828_012_1	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	1	1	02	01	H5828_012_1	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5828	012	2	1	02	01	H5828_012_2	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	2	1	02	01	H5828_012_2	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5828	012	2	1	02	01	H5828_012_2	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	2	1	02	01	H5828_012_2	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5828	012	2	1	02	01	H5828_012_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	2	1	02	01	H5828_012_2	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	2	1	02	01	H5828_012_2	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	2	1	02	01	H5828_012_2	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5828	012	3	1	02	01	H5828_012_3	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	3	1	02	01	H5828_012_3	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5828	012	3	1	02	01	H5828_012_3	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	3	1	02	01	H5828_012_3	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H5828	012	3	1	02	01	H5828_012_3	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	3	1	02	01	H5828_012_3	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	3	1	02	01	H5828_012_3	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5828	012	3	1	02	01	H5828_012_3	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5843	001	0	1	01	01	H5843_001_0	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H5843	001	0	1	01	01	H5843_001_0	8			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5843	001	0	1	01	01	H5843_001_0	8			Generic	4	01	1	2	2	1	110		01	100		1	31		90				1	2			90				31		31	5.00		15.00																					10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00						10.00				5.00		5.00
H5843	001	0	1	01	01	H5843_001_0	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5843	001	0	1	01	01	H5843_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					300.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5843	001	0	1	01	01	H5843_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				979.65	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5843	002	0	1	01	01	H5843_002_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H5843	002	0	1	01	01	H5843_002_0	10			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5843	002	0	1	01	01	H5843_002_0	10			Generic	4	01	1	2	2	1	110		01	100		1	31		90				1	2			90				31		31	5.00		15.00																					10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00						10.00				5.00		5.00
H5843	002	0	1	01	01	H5843_002_0	10			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5843	002	0	1	01	01	H5843_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					300.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5843	002	0	1	01	01	H5843_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				972.72	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5843	005	0	1	01	01	H5843_005_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H5843	005	0	1	01	01	H5843_005_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5843	005	0	1	01	01	H5843_005_0	7			Generic	4	01	1	2	2	1	110		01	100		1	31		90				1	2			90				31		31	5.00		15.00																					10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00						10.00				5.00		5.00
H5843	005	0	1	01	01	H5843_005_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5843	005	0	1	01	01	H5843_005_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					300.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H5843	005	0	1	01	01	H5843_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				1033.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5852	001	0	1	01	01	H5852_001_0	8			Generic	4	01	1	1	1	1	110		01			1	30		100				1	2							30		34				4.74	15		15																																			15			15								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00		35.00										35.00		35.00
H5852	001	0	1	01	01	H5852_001_0	8			Preferred Brand	4	11	1	1	2	1	110		01			1	30		100				1	2							30		34				80.94	15		15																																			15			15								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00		35.00										35.00		35.00
H5852	001	0	1	01	01	H5852_001_0	8			Non-Preferred Brand	4	10	1	1	3	1	110		01			1	30		100				1	2							30		34				259.19	25		25																																			25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5852	001	0	1	01	01	H5852_001_0	8			Specialty Tier	4	10	1	1	4	1	110		01			1	30		100				1	2							30		34				783.80	25		25																																			25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5852	001	0	1	01	01	H5852_001_0	8			Select Care Drugs	4	01	1	1	5	1	110		01			1	30		100				1	2							30		34				0.00	0		0																																			0			0								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H5852	001	0	1	01	01	H5852_001_0	8			Select Care Drugs	4	01	1	1	5	3	110		01			1	30		100				1	2							30		34				0.00	0		0																																			0			0								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H5854	009	0	1	01	01	H5854_009_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								17.00	34.00	51.00					12.00	24.00	36.00					0.00	0.00	0.00																17.00				17.00			0.57	0.40	0.00			0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	009	0	1	01	01	H5854_009_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	009	0	1	01	01	H5854_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H5854	009	0	1	01	01	H5854_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	009	0	1	01	01	H5854_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	009	0	1	01	01	H5854_009_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	009	0	1	01	01	H5854_009_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5854	010	0	1	01	01	H5854_010_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	010	0	1	01	01	H5854_010_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								19.00	38.00	57.00					14.00	28.00	42.00					0.00	0.00	0.00																19.00				19.00			0.63	0.47	0.00			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	010	0	1	01	01	H5854_010_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	105.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5854	010	0	1	01	01	H5854_010_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	010	0	1	01	01	H5854_010_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	010	0	1	01	01	H5854_010_0	5			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	010	0	1	01	01	H5854_010_0	5			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5854	011	0	1	01	01	H5854_011_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	011	0	1	01	01	H5854_011_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					15.00	30.00	45.00					15.00	45.00	45.00																15.00				15.00			0.50	0.50	0.50			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	011	0	1	01	01	H5854_011_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H5854	011	0	1	01	01	H5854_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	011	0	1	01	01	H5854_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	011	0	1	01	01	H5854_011_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								10.00	20.00	30.00					10.00	20.00	30.00					10.00	30.00	30.00																10.00				10.00			0.33	0.33	0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	012	0	1	02	01	H5854_012_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	012	0	1	02	01	H5854_012_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.00	28.00	42.00					9.00	18.00	27.00					0.00	0.00	0.00																14.00				14.00			0.47	0.30	0.00			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	012	0	1	02	01	H5854_012_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H5854	012	0	1	02	01	H5854_012_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								99.00	198.00	297.00					94.00	188.00	282.00					94.00	282.00	282.00																99.00				99.00			3.30	3.13	3.13			2.91	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	012	0	1	02	01	H5854_012_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	012	0	1	02	01	H5854_012_0	5			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	014	0	1	01	01	H5854_014_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	014	0	1	01	01	H5854_014_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5854	014	0	1	01	01	H5854_014_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	014	0	1	01	01	H5854_014_0	6			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5854	014	0	1	01	01	H5854_014_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5854	014	0	1	01	01	H5854_014_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H5854	014	0	1	01	01	H5854_014_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5854	014	0	1	01	01	H5854_014_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5854	014	0	1	01	01	H5854_014_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5859	001	0	1	02	01	H5859_001_0	9		N	Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5859	001	0	1	02	01	H5859_001_0	9		N	Preferred Brand	4	10	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5859	001	0	1	02	01	H5859_001_0	9		N	Non-Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5859	001	0	1	02	01	H5859_001_0	9		N	Specialty Tier	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					25	25	25																		25	25	25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5859	001	0	1	02	01	H5859_001_0	9		N	Supplemental Drugs	4	01	2	2	5	1	010		01	000		1	30														30		31	1.55																																							1.55				1.55		0.05						0.05	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H5883	002	1	1	02	01	H5883_002_1	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	1	1	02	01	H5883_002_1	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	002	1	1	02	01	H5883_002_1	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	1	1	02	01	H5883_002_1	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	002	1	1	02	01	H5883_002_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	45		45				76.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	002	1	1	02	01	H5883_002_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	002	2	1	02	01	H5883_002_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	2	1	02	01	H5883_002_2	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	002	2	1	02	01	H5883_002_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	2	1	02	01	H5883_002_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	002	2	1	02	01	H5883_002_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	45		45				76.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	002	2	1	02	01	H5883_002_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	002	3	1	02	01	H5883_002_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	3	1	02	01	H5883_002_3	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	002	3	1	02	01	H5883_002_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	3	1	02	01	H5883_002_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	002	3	1	02	01	H5883_002_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	45		45				76.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	002	3	1	02	01	H5883_002_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	002	4	1	02	01	H5883_002_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	4	1	02	01	H5883_002_4	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	002	4	1	02	01	H5883_002_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	4	1	02	01	H5883_002_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	002	4	1	02	01	H5883_002_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	45		45				76.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	002	4	1	02	01	H5883_002_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	002	7	1	02	01	H5883_002_7	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	7	1	02	01	H5883_002_7	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	002	7	1	02	01	H5883_002_7	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	002	7	1	02	01	H5883_002_7	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	002	7	1	02	01	H5883_002_7	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	45		45				76.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	002	7	1	02	01	H5883_002_7	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	003	1	1	02	01	H5883_003_1	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	1	1	02	01	H5883_003_1	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	003	1	1	02	01	H5883_003_1	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	1	1	02	01	H5883_003_1	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	003	1	1	02	01	H5883_003_1	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											76.00	45		45				79.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	003	1	1	02	01	H5883_003_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	003	2	1	02	01	H5883_003_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	2	1	02	01	H5883_003_2	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	003	2	1	02	01	H5883_003_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	2	1	02	01	H5883_003_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	003	2	1	02	01	H5883_003_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											76.00	45		45				79.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	003	2	1	02	01	H5883_003_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	003	3	1	02	01	H5883_003_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	3	1	02	01	H5883_003_3	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	003	3	1	02	01	H5883_003_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	3	1	02	01	H5883_003_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	003	3	1	02	01	H5883_003_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											76.00	45		45				79.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	003	3	1	02	01	H5883_003_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	003	4	1	02	01	H5883_003_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	4	1	02	01	H5883_003_4	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	003	4	1	02	01	H5883_003_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	4	1	02	01	H5883_003_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	003	4	1	02	01	H5883_003_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											76.00	45		45				79.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	003	4	1	02	01	H5883_003_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	003	5	1	02	01	H5883_003_5	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	5	1	02	01	H5883_003_5	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	003	5	1	02	01	H5883_003_5	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	003	5	1	02	01	H5883_003_5	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								43.00		129.00					38.00		114.00											43.00		129.00				38.00		76.00				43.00				43.00			1.39	1.23		1.39	1.23	1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		76.00	35.00		35.00
H5883	003	5	1	02	01	H5883_003_5	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											76.00	45		45				79.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	003	5	1	02	01	H5883_003_5	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	007	0	1	01	01	H5883_007_0	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	007	0	1	01	01	H5883_007_0	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	007	0	1	01	01	H5883_007_0	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					10.00		0.00											18.00		54.00				10.00		0.00				18.00				18.00			0.58	0.32		0.58	0.32	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	007	0	1	01	01	H5883_007_0	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H5883	007	0	1	01	01	H5883_007_0	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											85.00	46		46				71.00	46		46										46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	007	0	1	01	01	H5883_007_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	012	1	1	02	01	H5883_012_1	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	012	1	1	02	01	H5883_012_1	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	012	1	1	02	01	H5883_012_1	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H5883	012	1	1	02	01	H5883_012_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	012	1	1	02	01	H5883_012_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	012	2	1	02	01	H5883_012_2	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	012	2	1	02	01	H5883_012_2	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	012	2	1	02	01	H5883_012_2	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H5883	012	2	1	02	01	H5883_012_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											81.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	012	2	1	02	01	H5883_012_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	014	1	1	02	01	H5883_014_1	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	1	1	02	01	H5883_014_1	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	014	1	1	02	01	H5883_014_1	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	1	1	02	01	H5883_014_1	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H5883	014	1	1	02	01	H5883_014_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											85.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	014	1	1	02	01	H5883_014_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	014	2	1	02	01	H5883_014_2	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	2	1	02	01	H5883_014_2	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	014	2	1	02	01	H5883_014_2	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	2	1	02	01	H5883_014_2	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H5883	014	2	1	02	01	H5883_014_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											85.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	014	2	1	02	01	H5883_014_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	014	3	1	02	01	H5883_014_3	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	3	1	02	01	H5883_014_3	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	014	3	1	02	01	H5883_014_3	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	3	1	02	01	H5883_014_3	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H5883	014	3	1	02	01	H5883_014_3	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											85.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	014	3	1	02	01	H5883_014_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	014	4	1	02	01	H5883_014_4	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	4	1	02	01	H5883_014_4	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	014	4	1	02	01	H5883_014_4	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	4	1	02	01	H5883_014_4	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H5883	014	4	1	02	01	H5883_014_4	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											85.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	014	4	1	02	01	H5883_014_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	014	5	1	02	01	H5883_014_5	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	5	1	02	01	H5883_014_5	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H5883	014	5	1	02	01	H5883_014_5	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	014	5	1	02	01	H5883_014_5	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H5883	014	5	1	02	01	H5883_014_5	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											85.00	50		50				79.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	014	5	1	02	01	H5883_014_5	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5883	015	0	1	01	01	H5883_015_0	6			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	015	0	1	01	01	H5883_015_0	6			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5883	015	0	1	01	01	H5883_015_0	6			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H5883	015	0	1	01	01	H5883_015_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											76.00	50		50				69.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H5883	015	0	1	01	01	H5883_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H5900	001	0	1	04	01	H5900_001_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								8.00	16.00	24.00					0.00	0.00	0.00					0.00	0.00	0.00																8.00				0.00			0.27	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00				8.00		0.00
H5900	001	0	1	04	01	H5900_001_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	20.00	28.00					10.00	20.00	0.00																20.00				10.00			0.67	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	28.00	10.00	20.00	0.00				20.00		10.00
H5900	001	0	1	04	01	H5900_001_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					47.00	94.00	129.00					47.00	94.00	118.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	001	0	1	04	01	H5900_001_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	275.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	001	0	1	04	01	H5900_001_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1600.59	33						1309.30	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5900	002	0	1	04	01	H5900_002_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								6.00	12.00	18.00					0.00	0.00	0.00					0.00	0.00	0.00																6.00				0.00			0.20	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00				6.00		0.00
H5900	002	0	1	04	01	H5900_002_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								14.00	28.00	42.00					8.00	16.00	22.00					8.00	16.00	0.00																14.00				8.00			0.47	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00	8.00	16.00	22.00	8.00	16.00	0.00				14.00		8.00
H5900	002	0	1	04	01	H5900_002_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								36.00	72.00	108.00					35.00	70.00	96.00					35.00	70.00	88.00																36.00				36.00			1.20	1.17	1.17			1.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	96.00	35.00	70.00	88.00				35.00		35.00
H5900	002	0	1	04	01	H5900_002_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	275.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	002	0	1	04	01	H5900_002_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1331.18	33						1489.48	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5900	003	0	1	04	01	H5900_003_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					0.00	0.00	0.00					0.00	0.00	0.00																12.00				0.00			0.40	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00				12.00		0.00
H5900	003	0	1	04	01	H5900_003_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								18.00	36.00	54.00					10.00	20.00	28.00					10.00	20.00	0.00																18.00				10.00			0.60	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00	36.00	54.00	10.00	20.00	28.00	10.00	20.00	0.00				18.00		10.00
H5900	003	0	1	04	01	H5900_003_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					47.00	94.00	129.00					47.00	94.00	118.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	003	0	1	04	01	H5900_003_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	275.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	003	0	1	04	01	H5900_003_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1373.07	33						1167.46	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5900	004	0	1	04	01	H5900_004_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								6.00	12.00	18.00					0.00	0.00	0.00					0.00	0.00	0.00																6.00				0.00			0.20	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00				6.00		0.00
H5900	004	0	1	04	01	H5900_004_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								14.00	28.00	42.00					10.00	20.00	28.00					10.00	20.00	0.00																14.00				10.00			0.47	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00	10.00	20.00	28.00	10.00	20.00	0.00				14.00		10.00
H5900	004	0	1	04	01	H5900_004_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					47.00	94.00	129.00					47.00	94.00	118.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	004	0	1	04	01	H5900_004_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	275.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	004	0	1	04	01	H5900_004_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1397.01	33						1447.14	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5900	005	0	1	04	01	H5900_005_0	11			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					0.00	0.00	0.00					0.00	0.00	0.00																12.00				0.00			0.40	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00				12.00		0.00
H5900	005	0	1	04	01	H5900_005_0	11			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								15.00	30.00	45.00					7.00	14.00	19.00					7.00	14.00	0.00																15.00				7.00			0.50	0.23	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	7.00	14.00	19.00	7.00	14.00	0.00				15.00		7.00
H5900	005	0	1	04	01	H5900_005_0	11			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					47.00	94.00	129.00					47.00	94.00	118.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	005	0	1	04	01	H5900_005_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	275.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H5900	005	0	1	04	01	H5900_005_0	11			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1514.34	33						1514.34	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H5926	006	0	1	01	01	H5926_006_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	006	0	1	01	01	H5926_006_0	6			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	006	0	1	01	01	H5926_006_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H5926	006	0	1	01	01	H5926_006_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	006	0	1	01	01	H5926_006_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				934.02	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5926	006	0	1	01	01	H5926_006_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	007	0	1	01	01	H5926_007_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	007	0	1	01	01	H5926_007_0	4			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	007	0	1	01	01	H5926_007_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H5926	007	0	1	01	01	H5926_007_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5926	007	0	1	01	01	H5926_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1026.75	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5926	007	0	1	01	01	H5926_007_0	4			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5928	004	0	1	01	01	H5928_004_0	3			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5928	004	0	1	01	01	H5928_004_0	3			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5928	004	0	1	01	01	H5928_004_0	3			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	25.00					3.00	6.00	7.50							7.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5928	004	0	1	01	01	H5928_004_0	3			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	25.00					3.00	6.00	7.50							7.50																10.00				10.00			0.33	0.10				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5928	004	0	1	01	01	H5928_004_0	3			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	117.50					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H5928	004	0	1	01	01	H5928_004_0	3			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	250.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H5928	004	0	1	01	01	H5928_004_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5928	010	0	1	01	01	H5928_010_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								3.00	3.00	3.00					0.00	0.00	0.00							0.00																3.00				3.00			0.10	0.00				0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5928	010	0	1	01	01	H5928_010_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	100	2	2			100				30		31								3.00	3.00	3.00					0.00	0.00	0.00							0.00																3.00				3.00			0.10	0.00				0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5928	010	0	1	01	01	H5928_010_0	4			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	25.00					5.00	10.00	12.50							12.50																10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5928	010	0	1	01	01	H5928_010_0	4			Generic	4	01	1	2	2	3		111	01	100		1				30	60	90	2	2			90				30		31								10.00	20.00	25.00					5.00	10.00	12.50							12.50																10.00				10.00			0.33	0.16				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H5928	010	0	1	01	01	H5928_010_0	4			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	117.50					40.00	80.00	100.00							100.00																47.00				47.00			1.57	1.33				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	100.00			100.00				35.00		35.00
H5928	010	0	1	01	01	H5928_010_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01	100		1				30	60	90	2	2			90				30		31								100.00	200.00	250.00					95.00	190.00	237.50							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H5928	010	0	1	01	01	H5928_010_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5932	001	0	1	01	01	H5932_001_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	12.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5932	001	0	1	01	01	H5932_001_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	13.00	26.00	39.00																			13.00	26.00	39.00																13.00				13.00		0.43			0.43			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00				13.00	26.00	39.00				13.00		13.00
H5932	001	0	1	01	01	H5932_001_0	6		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	38.00	76.00	114.00																			38.00	76.00	114.00																38.00				38.00		1.27			1.27			1.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	001	0	1	01	01	H5932_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				48.91	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	001	0	1	01	01	H5932_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H5932	009	0	1	01	01	H5932_009_0	5		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	12.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5932	009	0	1	01	01	H5932_009_0	5		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H5932	009	0	1	01	01	H5932_009_0	5		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	009	0	1	01	01	H5932_009_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.21	46	46	46																		46	46	46															46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	009	0	1	01	01	H5932_009_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H5932	012	0	1	01	01	H5932_012_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	12.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5932	012	0	1	01	01	H5932_012_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	13.00	26.00	39.00																			13.00	26.00	39.00																13.00				13.00		0.43			0.43			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00				13.00	26.00	39.00				13.00		13.00
H5932	012	0	1	01	01	H5932_012_0	6		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	42.00	84.00	126.00																			42.00	84.00	126.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	012	0	1	01	01	H5932_012_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.50	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	012	0	1	01	01	H5932_012_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H5932	013	0	1	01	01	H5932_013_0	5		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	12.00																			4.00	8.00	12.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5932	013	0	1	01	01	H5932_013_0	5		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H5932	013	0	1	01	01	H5932_013_0	5		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	013	0	1	01	01	H5932_013_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				60.77	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5932	013	0	1	01	01	H5932_013_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H5938	001	0	1	01	01	H5938_001_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	001	0	1	01	01	H5938_001_0	12			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5938	001	0	1	01	01	H5938_001_0	12			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	001	0	1	01	01	H5938_001_0	12			Generic	4	01	1	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5938	001	0	1	01	01	H5938_001_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H5938	001	0	1	01	01	H5938_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	237.50																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H5938	001	0	1	01	01	H5938_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	001	0	1	01	01	H5938_001_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	001	0	1	01	01	H5938_001_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5938	006	0	1	01	01	H5938_006_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	006	0	1	01	01	H5938_006_0	12			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5938	006	0	1	01	01	H5938_006_0	12			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	006	0	1	01	01	H5938_006_0	12			Generic	4	01	1	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5938	006	0	1	01	01	H5938_006_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H5938	006	0	1	01	01	H5938_006_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	237.50																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H5938	006	0	1	01	01	H5938_006_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	006	0	1	01	01	H5938_006_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	006	0	1	01	01	H5938_006_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5938	008	0	1	01	01	H5938_008_0	12			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	008	0	1	01	01	H5938_008_0	12			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					7.00	14.00	21.00					7.00	14.00	17.50																14.00				14.00			0.47	0.23	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	008	0	1	01	01	H5938_008_0	12			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	87.50				35.00		35.00
H5938	008	0	1	01	01	H5938_008_0	12			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					93.00	186.00	279.00					93.00	186.00	232.50																100.00				100.00			3.33	3.10	3.10			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	87.50				35.00		35.00
H5938	008	0	1	01	01	H5938_008_0	12			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31												33							33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	008	0	1	01	01	H5938_008_0	12			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5938	008	0	1	01	01	H5938_008_0	12			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5943	001	0	1	02	01	H5943_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	001	0	1	02	01	H5943_001_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	001	0	1	02	01	H5943_001_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											73.11	25	25	25				73.11	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5943	001	0	1	02	01	H5943_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											76.20	25	25	25				76.20	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	001	0	1	02	01	H5943_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	001	0	1	02	01	H5943_001_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	002	0	1	02	01	H5943_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	002	0	1	02	01	H5943_002_0	7			Generic	4	11	1	1	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											5.46	25	25	25				5.46	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	002	0	1	02	01	H5943_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											62.55	25	25	25				62.55	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5943	002	0	1	02	01	H5943_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											62.10	25	25	25				62.10	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	002	0	1	02	01	H5943_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5943	002	0	1	02	01	H5943_002_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	001	0	1	01	01	H5945_001_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	001	0	1	01	01	H5945_001_0	7			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	001	0	1	01	01	H5945_001_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H5945	001	0	1	01	01	H5945_001_0	7			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	001	0	1	01	01	H5945_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5945	001	0	1	01	01	H5945_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	001	0	1	01	01	H5945_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				97.44	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	001	0	1	01	01	H5945_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	001	0	1	01	01	H5945_001_0	7			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	002	0	1	01	01	H5945_002_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	002	0	1	01	01	H5945_002_0	7			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	002	0	1	01	01	H5945_002_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H5945	002	0	1	01	01	H5945_002_0	7			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	002	0	1	01	01	H5945_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5945	002	0	1	01	01	H5945_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	002	0	1	01	01	H5945_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				127.86	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	002	0	1	01	01	H5945_002_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	002	0	1	01	01	H5945_002_0	7			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	008	0	1	01	01	H5945_008_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	008	0	1	01	01	H5945_008_0	7			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	008	0	1	01	01	H5945_008_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H5945	008	0	1	01	01	H5945_008_0	7			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	008	0	1	01	01	H5945_008_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	20.00	40.00	40.00																					40.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00	40.00	40.00						40.00				20.00		20.00
H5945	008	0	1	01	01	H5945_008_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	97.00	194.00	281.00																					281.00																97.00				97.00		3.23						3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	008	0	1	01	01	H5945_008_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				107.93	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	008	0	1	01	01	H5945_008_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	008	0	1	01	01	H5945_008_0	7			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	009	0	1	01	01	H5945_009_0	7		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				0.99	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	009	0	1	01	01	H5945_009_0	7		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				5.56	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	009	0	1	01	01	H5945_009_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				143.07	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	009	0	1	01	01	H5945_009_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				53.50	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	009	0	1	01	01	H5945_009_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				192.16	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	009	0	1	01	01	H5945_009_0	7		N	Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.78	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	013	0	1	01	01	H5945_013_0	7			Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.23	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	013	0	1	01	01	H5945_013_0	7			Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				5.41	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	013	0	1	01	01	H5945_013_0	7			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				140.81	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	013	0	1	01	01	H5945_013_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				40.29	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	013	0	1	01	01	H5945_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				183.50	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	013	0	1	01	01	H5945_013_0	7			Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				1.05	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	014	0	1	01	01	H5945_014_0	7			Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.19	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	014	0	1	01	01	H5945_014_0	7			Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				5.35	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	014	0	1	01	01	H5945_014_0	7			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				139.62	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	014	0	1	01	01	H5945_014_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				42.05	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	014	0	1	01	01	H5945_014_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				177.75	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	014	0	1	01	01	H5945_014_0	7			Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.97	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	016	0	1	01	01	H5945_016_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	016	0	1	01	01	H5945_016_0	6			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	016	0	1	01	01	H5945_016_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H5945	016	0	1	01	01	H5945_016_0	6			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	016	0	1	01	01	H5945_016_0	6			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5945	016	0	1	01	01	H5945_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	016	0	1	01	01	H5945_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				119.42	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	016	0	1	01	01	H5945_016_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	016	0	1	01	01	H5945_016_0	6			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	017	0	1	01	01	H5945_017_0	8		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.19	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	017	0	1	01	01	H5945_017_0	8		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				6.39	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	017	0	1	01	01	H5945_017_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				158.65	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	017	0	1	01	01	H5945_017_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				63.29	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	017	0	1	01	01	H5945_017_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				262.88	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	017	0	1	01	01	H5945_017_0	8		N	Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.82	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	018	0	1	01	01	H5945_018_0	7		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.16	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	018	0	1	01	01	H5945_018_0	7		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				6.46	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	018	0	1	01	01	H5945_018_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				160.16	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H5945	018	0	1	01	01	H5945_018_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				69.27	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	018	0	1	01	01	H5945_018_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				281.52	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	018	0	1	01	01	H5945_018_0	7		N	Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.75	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	020	0	1	01	01	H5945_020_0	5			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	020	0	1	01	01	H5945_020_0	5			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	020	0	1	01	01	H5945_020_0	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H5945	020	0	1	01	01	H5945_020_0	5			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	020	0	1	01	01	H5945_020_0	5			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5945	020	0	1	01	01	H5945_020_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	020	0	1	01	01	H5945_020_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				123.57	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	020	0	1	01	01	H5945_020_0	5			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	020	0	1	01	01	H5945_020_0	5			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	021	0	1	01	01	H5945_021_0	5			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	021	0	1	01	01	H5945_021_0	5			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	021	0	1	01	01	H5945_021_0	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H5945	021	0	1	01	01	H5945_021_0	5			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	021	0	1	01	01	H5945_021_0	5			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5945	021	0	1	01	01	H5945_021_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	021	0	1	01	01	H5945_021_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				153.10	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	021	0	1	01	01	H5945_021_0	5			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	021	0	1	01	01	H5945_021_0	5			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	027	0	1	01	01	H5945_027_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	027	0	1	01	01	H5945_027_0	6			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H5945	027	0	1	01	01	H5945_027_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H5945	027	0	1	01	01	H5945_027_0	6			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5945	027	0	1	01	01	H5945_027_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				137.60	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H5945	027	0	1	01	01	H5945_027_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				37.90	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	027	0	1	01	01	H5945_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				153.24	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	027	0	1	01	01	H5945_027_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5945	027	0	1	01	01	H5945_027_0	6			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H5959	009	0	1	04	01	H5959_009_0	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	009	0	1	04	01	H5959_009_0	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	10.00	20.00	20.00																									15.00	30.00	30.00				10.00	20.00	20.00				10.00				10.00		0.32				0.48	0.32	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00				15.00	30.00	30.00	10.00	20.00	20.00	10.00		10.00
H5959	009	0	1	04	01	H5959_009_0	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.52				1.61	1.52	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	009	0	1	04	01	H5959_009_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				70.96	42	42	42																								44	44	44				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	009	0	1	04	01	H5959_009_0	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					33	33	33																								33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	010	1	1	04	01	H5959_010_1	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	010	1	1	04	01	H5959_010_1	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	9.00	18.00	18.00																									14.00	28.00	28.00				9.00	18.00	18.00				9.00				9.00		0.29				0.45	0.29	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	18.00				14.00	28.00	28.00	9.00	18.00	18.00	9.00		9.00
H5959	010	1	1	04	01	H5959_010_1	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.51				1.61	1.52	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	010	1	1	04	01	H5959_010_1	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				80.89	45	45	45																								47	47	47				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	010	1	1	04	01	H5959_010_1	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					33	33	33																								33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	010	2	1	04	01	H5959_010_2	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	010	2	1	04	01	H5959_010_2	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	9.00	18.00	18.00																									14.00	28.00	28.00				9.00	18.00	18.00				9.00				9.00		0.29				0.45	0.29	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	18.00				14.00	28.00	28.00	9.00	18.00	18.00	9.00		9.00
H5959	010	2	1	04	01	H5959_010_2	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.51				1.61	1.52	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	010	2	1	04	01	H5959_010_2	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				80.89	45	45	45																								47	47	47				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	010	2	1	04	01	H5959_010_2	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					33	33	33																								33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	011	0	1	04	01	H5959_011_0	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	011	0	1	04	01	H5959_011_0	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	9.00	18.00	18.00																									14.00	28.00	28.00				9.00	18.00	18.00				9.00				9.00		0.29				0.45	0.29	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	18.00				14.00	28.00	28.00	9.00	18.00	18.00	9.00		9.00
H5959	011	0	1	04	01	H5959_011_0	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.51				1.61	1.52	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	011	0	1	04	01	H5959_011_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				85.07	45	45	45																								47	47	47				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	011	0	1	04	01	H5959_011_0	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					33	33	33																								33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	012	0	1	04	01	H5959_012_0	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	012	0	1	04	01	H5959_012_0	7			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	13.00	26.00	26.00																									18.00	36.00	36.00				13.00	26.00	26.00				13.00				13.00		0.41				0.58	0.41	0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	26.00				18.00	36.00	36.00	13.00	26.00	26.00	13.00		13.00
H5959	012	0	1	04	01	H5959_012_0	7			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				53.45	21	21	21																								23	23	23				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	012	0	1	04	01	H5959_012_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				82.89	45	45	45																								47	47	47				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	012	0	1	04	01	H5959_012_0	7			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					27	27	27																								27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	013	1	1	04	01	H5959_013_1	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	013	1	1	04	01	H5959_013_1	7			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	13.00	26.00	26.00																									18.00	36.00	36.00				13.00	26.00	26.00				13.00				13.00		0.41				0.58	0.41	0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	26.00				18.00	36.00	36.00	13.00	26.00	26.00	13.00		13.00
H5959	013	1	1	04	01	H5959_013_1	7			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				53.90	21	21	21																								23	23	23				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	013	1	1	04	01	H5959_013_1	7			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				81.09	45	45	45																								47	47	47				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	013	1	1	04	01	H5959_013_1	7			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					27	27	27																								27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	013	2	1	04	01	H5959_013_2	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	013	2	1	04	01	H5959_013_2	7			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	13.00	26.00	26.00																									18.00	36.00	36.00				13.00	26.00	26.00				13.00				13.00		0.41				0.58	0.41	0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	26.00				18.00	36.00	36.00	13.00	26.00	26.00	13.00		13.00
H5959	013	2	1	04	01	H5959_013_2	7			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				53.90	21	21	21																								23	23	23				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	013	2	1	04	01	H5959_013_2	7			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				81.09	45	45	45																								47	47	47				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	013	2	1	04	01	H5959_013_2	7			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					27	27	27																								27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	014	1	1	04	01	H5959_014_1	9			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	014	1	1	04	01	H5959_014_1	9			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	10.00	20.00	20.00																									15.00	30.00	30.00				10.00	20.00	20.00				10.00				10.00		0.32				0.48	0.32	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00				15.00	30.00	30.00	10.00	20.00	20.00	10.00		10.00
H5959	014	1	1	04	01	H5959_014_1	9			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.52				1.61	1.52	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	014	1	1	04	01	H5959_014_1	9			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				64.07	42	42	42																								44	44	44				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	014	1	1	04	01	H5959_014_1	9			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					33	33	33																								33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	014	2	1	04	01	H5959_014_2	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	014	2	1	04	01	H5959_014_2	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	10.00	20.00	20.00																									15.00	30.00	30.00				10.00	20.00	20.00				10.00				10.00		0.32				0.48	0.32	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00				15.00	30.00	30.00	10.00	20.00	20.00	10.00		10.00
H5959	014	2	1	04	01	H5959_014_2	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.52				1.61	1.52	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	014	2	1	04	01	H5959_014_2	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				64.07	42	42	42																								44	44	44				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	014	2	1	04	01	H5959_014_2	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					33	33	33																								33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	015	0	1	04	01	H5959_015_0	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	015	0	1	04	01	H5959_015_0	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	11.00	22.00	22.00																									16.00	32.00	32.00				11.00	22.00	22.00				11.00				11.00		0.35				0.51	0.35	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	22.00				16.00	32.00	32.00	11.00	22.00	22.00	11.00		11.00
H5959	015	0	1	04	01	H5959_015_0	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.51				1.61	1.51	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	015	0	1	04	01	H5959_015_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				71.13	42	42	42																								44	44	44				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	015	0	1	04	01	H5959_015_0	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					28	28	28																								28	28	28				28	28	28			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5959	016	0	1	04	01	H5959_016_0	8			Preferred Generic	4	01	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									5.00	10.00	10.00				0.00	0.00	0.00				0.00				0.00		0.00				0.16	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				5.00	10.00	10.00	0.00	0.00	0.00	0.00		0.00
H5959	016	0	1	04	01	H5959_016_0	8			Generic	4	01	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	11.00	22.00	22.00																									16.00	32.00	32.00				11.00	22.00	22.00				11.00				11.00		0.35				0.51	0.35	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													11.00	22.00	22.00				16.00	32.00	32.00	11.00	22.00	22.00	11.00		11.00
H5959	016	0	1	04	01	H5959_016_0	8			Preferred Brand	4	11	1	2	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	47.00	94.00	94.00																									50.00	100.00	100.00				47.00	94.00	94.00				47.00				47.00		1.51				1.61	1.51	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	016	0	1	04	01	H5959_016_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				76.85	42	42	42																								44	44	44				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H5959	016	0	1	04	01	H5959_016_0	8			Specialty Tier	4	11	1	1	5	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31					27	27	27																								27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H5965	002	0	1	04	01	H5965_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5965	002	0	1	04	01	H5965_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5965	002	0	1	04	01	H5965_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5965	002	0	1	04	01	H5965_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.73	50	50	50				80.73	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5965	002	0	1	04	01	H5965_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5965	002	0	1	04	01	H5965_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5965	005	0	1	04	01	H5965_005_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5965	005	0	1	04	01	H5965_005_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5965	005	0	1	04	01	H5965_005_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H5965	005	0	1	04	01	H5965_005_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.70	50	50	50				90.70	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H5965	005	0	1	04	01	H5965_005_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H5965	005	0	1	04	01	H5965_005_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5970	001	0	1	04	01	H5970_001_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5970	001	0	1	04	01	H5970_001_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	001	0	1	04	01	H5970_001_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H5970	001	0	1	04	01	H5970_001_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	001	0	1	04	01	H5970_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	001	0	1	04	01	H5970_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	001	0	1	04	01	H5970_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5970	015	0	1	04	01	H5970_015_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5970	015	0	1	04	01	H5970_015_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	015	0	1	04	01	H5970_015_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5970	015	0	1	04	01	H5970_015_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	015	0	1	04	01	H5970_015_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	015	0	1	04	01	H5970_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	015	0	1	04	01	H5970_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5970	018	0	1	04	01	H5970_018_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5970	018	0	1	04	01	H5970_018_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	018	0	1	04	01	H5970_018_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5970	018	0	1	04	01	H5970_018_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	018	0	1	04	01	H5970_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	018	0	1	04	01	H5970_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	018	0	1	04	01	H5970_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5970	024	1	1	04	01	H5970_024_1	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5970	024	1	1	04	01	H5970_024_1	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5970	024	1	1	04	01	H5970_024_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	024	1	1	04	01	H5970_024_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	024	1	1	04	01	H5970_024_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5970	024	2	1	04	01	H5970_024_2	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H5970	024	2	1	04	01	H5970_024_2	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	9.00		27.00																									20.00		60.00				9.00		0.00				9.00				9.00		0.30				0.67	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00
H5970	024	2	1	04	01	H5970_024_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	024	2	1	04	01	H5970_024_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	024	2	1	04	01	H5970_024_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5970	025	0	1	04	01	H5970_025_0	9			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5970	025	0	1	04	01	H5970_025_0	9			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	025	0	1	04	01	H5970_025_0	9			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5970	025	0	1	04	01	H5970_025_0	9			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	025	0	1	04	01	H5970_025_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	025	0	1	04	01	H5970_025_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	025	0	1	04	01	H5970_025_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5970	027	0	1	04	01	H5970_027_0	9			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H5970	027	0	1	04	01	H5970_027_0	9			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	027	0	1	04	01	H5970_027_0	9			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H5970	027	0	1	04	01	H5970_027_0	9			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H5970	027	0	1	04	01	H5970_027_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	027	0	1	04	01	H5970_027_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H5970	027	0	1	04	01	H5970_027_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H5989	011	0	1	01	01	H5989_011_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H5989	011	0	1	01	01	H5989_011_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	10.00																			10.00	20.00	10.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													10.00	20.00	10.00				10.00	20.00	10.00				10.00		10.00
H5989	011	0	1	01	01	H5989_011_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	47.00																			47.00	94.00	47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H5989	011	0	1	01	01	H5989_011_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H5989	011	0	1	01	01	H5989_011_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H5989	011	0	1	01	01	H5989_011_0	10			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H5989	011	0	1	01	01	H5989_011_0	10			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H5991	010	0	1	01	01	H5991_010_0	11		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	010	0	1	01	01	H5991_010_0	11		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	42.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	010	0	1	01	01	H5991_010_0	11		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5991	010	0	1	01	01	H5991_010_0	11		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	010	0	1	01	01	H5991_010_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5991	010	0	1	01	01	H5991_010_0	11		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	1	1	01	01	H5991_012_1	10		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	1	1	01	01	H5991_012_1	10		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	36.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	1	1	01	01	H5991_012_1	10		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5991	012	1	1	01	01	H5991_012_1	10		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	1	1	01	01	H5991_012_1	10		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5991	012	1	1	01	01	H5991_012_1	10		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	2	1	01	01	H5991_012_2	11		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	2	1	01	01	H5991_012_2	11		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	36.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	2	1	01	01	H5991_012_2	11		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H5991	012	2	1	01	01	H5991_012_2	11		N	Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H5991	012	2	1	01	01	H5991_012_2	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H5991	012	2	1	01	01	H5991_012_2	11		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6018	001	0	1	04	01	H6018_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6018	001	0	1	04	01	H6018_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6018	001	0	1	04	01	H6018_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H6018	001	0	1	04	01	H6018_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6018	001	0	1	04	01	H6018_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6018	001	0	1	04	01	H6018_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6018	001	0	1	04	01	H6018_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6018	002	0	1	04	01	H6018_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6018	002	0	1	04	01	H6018_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6018	002	0	1	04	01	H6018_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H6018	002	0	1	04	01	H6018_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6018	002	0	1	04	01	H6018_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6018	002	0	1	04	01	H6018_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H6018	002	0	1	04	01	H6018_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6018	003	0	1	04	01	H6018_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6018	003	0	1	04	01	H6018_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6018	003	0	1	04	01	H6018_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H6018	003	0	1	04	01	H6018_003_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H6018	003	0	1	04	01	H6018_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6018	003	0	1	04	01	H6018_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6018	003	0	1	04	01	H6018_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6019	001	0	1	01	01	H6019_001_0	4		N	Generic	4	01	3	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				6.64	24	24	24																		24	24	24															24			24								Generic, Brand													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6019	001	0	1	01	01	H6019_001_0	4		N	Brand	4	10	3	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				143.09	25	25	25																		25	25	25															25			25								Generic, Brand													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6067	001	1	1	01	01	H6067_001_1	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	4.00	4.00																			4.00	4.00	4.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	4.00	4.00				4.00	4.00	4.00				4.00		4.00
H6067	001	1	1	01	01	H6067_001_1	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	20.00	20.00																			20.00	20.00	20.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	20.00	20.00				20.00	20.00	20.00				20.00		20.00
H6067	001	1	1	01	01	H6067_001_1	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	001	1	1	01	01	H6067_001_1	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				100.00	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	001	1	1	01	01	H6067_001_1	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6067	001	2	1	01	01	H6067_001_2	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	4.00	4.00																			4.00	4.00	4.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	4.00	4.00				4.00	4.00	4.00				4.00		4.00
H6067	001	2	1	01	01	H6067_001_2	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	20.00	20.00																			20.00	20.00	20.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	20.00	20.00				20.00	20.00	20.00				20.00		20.00
H6067	001	2	1	01	01	H6067_001_2	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	001	2	1	01	01	H6067_001_2	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				100.00	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	001	2	1	01	01	H6067_001_2	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6067	002	1	1	01	01	H6067_002_1	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	2.00	2.00																			2.00	2.00	2.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	2.00	2.00				2.00	2.00	2.00				2.00		2.00
H6067	002	1	1	01	01	H6067_002_1	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	2.00	2.00																			2.00	2.00	2.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6067	002	1	1	01	01	H6067_002_1	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	15.00	15.00	15.00																			15.00	15.00	15.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	15.00	15.00				15.00	15.00	15.00				15.00		15.00
H6067	002	1	1	01	01	H6067_002_1	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	002	1	1	01	01	H6067_002_1	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				100.00	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	002	1	1	01	01	H6067_002_1	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6067	002	2	1	01	01	H6067_002_2	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	2.00	2.00																			2.00	2.00	2.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	2.00	2.00				2.00	2.00	2.00				2.00		2.00
H6067	002	2	1	01	01	H6067_002_2	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	2.00	2.00																			2.00	2.00	2.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6067	002	2	1	01	01	H6067_002_2	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	15.00	15.00	15.00																			15.00	15.00	15.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	15.00	15.00				15.00	15.00	15.00				15.00		15.00
H6067	002	2	1	01	01	H6067_002_2	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	002	2	1	01	01	H6067_002_2	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				100.00	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6067	002	2	1	01	01	H6067_002_2	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				100.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6080	001	0	1	48	05	H6080_001_0	15			Generic Drugs	4	01		2	1	1	110		01	100		1	30		100				2	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H6080	001	0	1	48	05	H6080_001_0	15			Brand Drugs	4	10		2	2	1	110		01	100		1	30		100				2	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H6080	001	0	1	48	05	H6080_001_0	15			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	110		01	100		1	30		100				2	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H6154	001	0	1	02	01	H6154_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6154	001	0	1	02	01	H6154_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					14.00	28.00	42.00											20.00	40.00	60.00				14.00	28.00	32.00				20.00				14.00			0.67	0.47		0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	14.00	28.00	42.00	20.00	40.00	60.00	14.00	28.00	32.00	20.00		20.00
H6154	001	0	1	02	01	H6154_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6154	001	0	1	02	01	H6154_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											90.69	47	47	47				101.11	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6154	001	0	1	02	01	H6154_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6158	001	0	1	01	01	H6158_001_0	4			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6158	001	0	1	01	01	H6158_001_0	4			Generic	4	11	3	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	8.00		16.00																			8.00		0.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6158	001	0	1	01	01	H6158_001_0	4			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		94.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00		40.00				20.00		40.00				20.00		20.00
H6158	001	0	1	01	01	H6158_001_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				1	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00		60.00				20.00		60.00				20.00		20.00
H6158	001	0	1	01	01	H6158_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				935.37	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													20.00						20.00						20.00		20.00
H6158	001	0	1	01	01	H6158_001_0	4			Select Care Drugs	4	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6158	001	0	1	01	01	H6158_001_0	4			Select Care Drugs	4	11	1	2	6	3	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6158	003	0	1	01	01	H6158_003_0	3			Preferred Generic	3	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	7.00		14.00																			7.00		14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6158	003	0	1	01	01	H6158_003_0	3			Generic	3	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	20.00		40.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6158	003	0	1	01	01	H6158_003_0	3			Preferred Brand	3	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		94.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00				35.00		70.00				35.00		35.00
H6158	003	0	1	01	01	H6158_003_0	3			Non-Preferred Drug	3	11	1	2	4	1	110		01	110		1	30		100				1	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
H6158	003	0	1	01	01	H6158_003_0	3			Specialty Tier	3	11	1	1	5	1	010		01	010		1	30								30						30		31				972.29	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H6158	003	0	1	01	01	H6158_003_0	3			Select Care Drugs	3	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6170	001	0	1	01	01	H6170_001_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6170	001	0	1	01	01	H6170_001_0	7			Preferred Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H6170	001	0	1	01	01	H6170_001_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	8.00		24.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													8.00		24.00						16.00				8.00		8.00
H6170	001	0	1	01	01	H6170_001_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	001	0	1	01	01	H6170_001_0	7			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	100.00		300.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	001	0	1	01	01	H6170_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				514.85	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00												20.00		20.00
H6170	001	0	1	01	01	H6170_001_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6170	001	0	1	01	01	H6170_001_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6170	002	0	1	01	01	H6170_002_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6170	002	0	1	01	01	H6170_002_0	7			Preferred Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H6170	002	0	1	01	01	H6170_002_0	7			Generic	4	01	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31				9.53	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	002	0	1	01	01	H6170_002_0	7			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				104.38	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	002	0	1	01	01	H6170_002_0	7			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				56.13	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	002	0	1	01	01	H6170_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				473.95	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00												20.00		20.00
H6170	002	0	1	01	01	H6170_002_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6170	002	0	1	01	01	H6170_002_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6170	003	0	1	01	01	H6170_003_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6170	003	0	1	01	01	H6170_003_0	7			Preferred Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H6170	003	0	1	01	01	H6170_003_0	7			Generic	4	01	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31				7.63	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	003	0	1	01	01	H6170_003_0	7			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				96.44	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	003	0	1	01	01	H6170_003_0	7			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				52.30	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6170	003	0	1	01	01	H6170_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				441.73	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00												20.00		20.00
H6170	003	0	1	01	01	H6170_003_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6170	003	0	1	01	01	H6170_003_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6193	001	0	1	01	01	H6193_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6193	001	0	1	01	01	H6193_001_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6193	001	0	1	01	01	H6193_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6193	001	0	1	01	01	H6193_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.21	48	48	48				98.21	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6193	001	0	1	01	01	H6193_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6193	001	0	1	01	01	H6193_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6200	001	0	1	04	01	H6200_001_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	001	0	1	04	01	H6200_001_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	001	0	1	04	01	H6200_001_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	001	0	1	04	01	H6200_001_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	001	0	1	04	01	H6200_001_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	001	0	1	04	01	H6200_001_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	001	0	1	04	01	H6200_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6200	002	0	1	04	01	H6200_002_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	002	0	1	04	01	H6200_002_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	002	0	1	04	01	H6200_002_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	002	0	1	04	01	H6200_002_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	002	0	1	04	01	H6200_002_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	002	0	1	04	01	H6200_002_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	002	0	1	04	01	H6200_002_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6200	003	0	1	04	01	H6200_003_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	003	0	1	04	01	H6200_003_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	003	0	1	04	01	H6200_003_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	003	0	1	04	01	H6200_003_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	003	0	1	04	01	H6200_003_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	003	0	1	04	01	H6200_003_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	003	0	1	04	01	H6200_003_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6200	004	0	1	04	01	H6200_004_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	004	0	1	04	01	H6200_004_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	004	0	1	04	01	H6200_004_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	004	0	1	04	01	H6200_004_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	004	0	1	04	01	H6200_004_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	004	0	1	04	01	H6200_004_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	004	0	1	04	01	H6200_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6200	005	0	1	04	01	H6200_005_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	005	0	1	04	01	H6200_005_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	005	0	1	04	01	H6200_005_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	005	0	1	04	01	H6200_005_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	005	0	1	04	01	H6200_005_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	005	0	1	04	01	H6200_005_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	005	0	1	04	01	H6200_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6200	006	0	1	04	01	H6200_006_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	006	0	1	04	01	H6200_006_0	4			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	006	0	1	04	01	H6200_006_0	4			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	006	0	1	04	01	H6200_006_0	4			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	006	0	1	04	01	H6200_006_0	4			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	006	0	1	04	01	H6200_006_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	006	0	1	04	01	H6200_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6200	007	0	1	04	01	H6200_007_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00			0.00				4.00		4.00
H6200	007	0	1	04	01	H6200_007_0	5			Preferred Generic	4	01	1	2	1	3		111	01	100		1				30	60	90	1	2			90				30		31								4.00	8.00	12.00					0.00	0.00	0.00							0.00																4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H6200	007	0	1	04	01	H6200_007_0	5			Generic	4	01	3	2	2	1		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													12.00	24.00	36.00	0.00	0.00	0.00			0.00				12.00		12.00
H6200	007	0	1	04	01	H6200_007_0	5			Generic	4	01	3	2	2	3		111	01	100		1				30	60	90	1	2			90				30		31								12.00	24.00	36.00					0.00	0.00	0.00							0.00																12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H6200	007	0	1	04	01	H6200_007_0	5			Preferred Brand	4	10	1	2	3	1		111	01	100		1				30	60	90	1	2			90				30		31								47.00	94.00	141.00					45.00	90.00	135.00							112.50																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	007	0	1	04	01	H6200_007_0	5			Non-Preferred Brand	4	11	1	2	4	1		111	01	100		1				30	60	90	1	2			90				30		31								100.00	200.00	300.00					95.00	190.00	285.00							237.50																100.00				100.00			3.33	3.17				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
H6200	007	0	1	04	01	H6200_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6202	001	0	1	04	01	H6202_001_0	13			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	001	0	1	04	01	H6202_001_0	13			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			8.00	16.00	0.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	001	0	1	04	01	H6202_001_0	13			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	39.00	78.00	117.00																			39.00	78.00	98.00																39.00				39.00		1.30			1.30			1.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	98.00				35.00		35.00
H6202	001	0	1	04	01	H6202_001_0	13			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	001	0	1	04	01	H6202_001_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				755.19	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	001	0	1	04	01	H6202_001_0	13			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	002	0	1	04	01	H6202_002_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	002	0	1	04	01	H6202_002_0	11			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			6.00	12.00	0.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	002	0	1	04	01	H6202_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	39.00	78.00	117.00																			39.00	78.00	98.00																39.00				39.00		1.30			1.30			1.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	98.00				35.00		35.00
H6202	002	0	1	04	01	H6202_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	002	0	1	04	01	H6202_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				946.92	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6202	002	0	1	04	01	H6202_002_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6237	007	1	1	01	01	H6237_007_1	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6237	007	1	1	01	01	H6237_007_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H6237	007	1	1	01	01	H6237_007_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	007	1	1	01	01	H6237_007_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	007	1	1	01	01	H6237_007_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6237	007	3	1	01	01	H6237_007_3	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6237	007	3	1	01	01	H6237_007_3	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H6237	007	3	1	01	01	H6237_007_3	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	007	3	1	01	01	H6237_007_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	007	3	1	01	01	H6237_007_3	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6237	007	4	1	01	01	H6237_007_4	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6237	007	4	1	01	01	H6237_007_4	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	24.00	36.00					12.00	24.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	12.00	24.00	0.00				20.00		20.00
H6237	007	4	1	01	01	H6237_007_4	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	007	4	1	01	01	H6237_007_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	007	4	1	01	01	H6237_007_4	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1223.59	33						1223.59	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6237	008	1	1	01	01	H6237_008_1	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6237	008	1	1	01	01	H6237_008_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H6237	008	1	1	01	01	H6237_008_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H6237	008	1	1	01	01	H6237_008_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	008	1	1	01	01	H6237_008_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1149.44	31						1149.44	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6237	008	3	1	01	01	H6237_008_3	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	20.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6237	008	3	1	01	01	H6237_008_3	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	40.00					8.00	16.00	16.00					8.00	16.00	16.00																20.00				20.00			0.67	0.27	0.27			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	8.00	16.00	16.00	8.00	16.00	16.00				20.00		20.00
H6237	008	3	1	01	01	H6237_008_3	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	117.50					40.00	80.00	100.00					40.00	80.00	100.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00				35.00		35.00
H6237	008	3	1	01	01	H6237_008_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	250.00					100.00	200.00	250.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6237	008	3	1	01	01	H6237_008_3	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1149.44	31						1149.44	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6248	001	0	1	01	01	H6248_001_0	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	31	62	93				2	2			93				31		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6248	001	0	1	01	01	H6248_001_0	7			Preferred Generic	4	01	1	2	1	3	111		01	100		1	31	62	93				2	2			93				31		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6248	001	0	1	01	01	H6248_001_0	7			Generic	4	01	1	2	2	1	111		01	100		1	31	62	93				2	2			93				31		31	9.00	18.00	27.00																					27.00																9.00				9.00		0.29						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													9.00	18.00	27.00						27.00				9.00		9.00
H6248	001	0	1	01	01	H6248_001_0	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	31	62	93				2	2			93				31		31	47.00	94.00	141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H6248	001	0	1	01	01	H6248_001_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	31	62	93				2	2			93				31		31	90.00	180.00	270.00																					270.00																90.00				90.00		2.90						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6248	001	0	1	01	01	H6248_001_0	7			Specialty Tier	4	11	1	1	5	1	111		01	010		1	31	62	93				2	2	31						31		31				2344.55	33	33	33																		33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6248	001	0	1	01	01	H6248_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	31	62	93				2	2			93				31		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6248	001	0	1	01	01	H6248_001_0	7			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	31	62	93				2	2			93				31		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6306	005	0	1	01	01	H6306_005_0	10			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	005	0	1	01	01	H6306_005_0	10			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6306	005	0	1	01	01	H6306_005_0	10			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H6306	005	0	1	01	01	H6306_005_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6306	005	0	1	01	01	H6306_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6306	005	0	1	01	01	H6306_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	013	0	1	02	01	H6306_013_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	6.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	013	0	1	02	01	H6306_013_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	6.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6306	013	0	1	02	01	H6306_013_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	20.00	0.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00				8.00	20.00	0.00				8.00		8.00
H6306	013	0	1	02	01	H6306_013_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H6306	013	0	1	02	01	H6306_013_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H6306	013	0	1	02	01	H6306_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				881.70	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	014	0	1	02	01	H6306_014_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	6.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	014	0	1	02	01	H6306_014_0	8			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	6.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6306	014	0	1	02	01	H6306_014_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	8.00	16.00	24.00																			8.00	20.00	0.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00				8.00	20.00	0.00				8.00		8.00
H6306	014	0	1	02	01	H6306_014_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H6306	014	0	1	02	01	H6306_014_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				83.28	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H6306	014	0	1	02	01	H6306_014_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				935.03	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	017	0	1	02	01	H6306_017_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	017	0	1	02	01	H6306_017_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6306	017	0	1	02	01	H6306_017_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	37.50																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	37.50				15.00		15.00
H6306	017	0	1	02	01	H6306_017_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H6306	017	0	1	02	01	H6306_017_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.41	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6306	017	0	1	02	01	H6306_017_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	018	0	1	02	01	H6306_018_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6306	018	0	1	02	01	H6306_018_0	8			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6306	018	0	1	02	01	H6306_018_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	50.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	50.00				20.00		20.00
H6306	018	0	1	02	01	H6306_018_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H6306	018	0	1	02	01	H6306_018_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6306	018	0	1	02	01	H6306_018_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6322	001	0	1	01	01	H6322_001_0	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	001	0	1	01	01	H6322_001_0	7			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	001	0	1	01	01	H6322_001_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H6322	001	0	1	01	01	H6322_001_0	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	001	0	1	01	01	H6322_001_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	001	0	1	01	01	H6322_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H6322	001	0	1	01	01	H6322_001_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	001	0	1	01	01	H6322_001_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	002	0	1	01	01	H6322_002_0	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	002	0	1	01	01	H6322_002_0	7			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	002	0	1	01	01	H6322_002_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H6322	002	0	1	01	01	H6322_002_0	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	002	0	1	01	01	H6322_002_0	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	002	0	1	01	01	H6322_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H6322	002	0	1	01	01	H6322_002_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	002	0	1	01	01	H6322_002_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	003	1	1	02	01	H6322_003_1	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	003	1	1	02	01	H6322_003_1	7			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	003	1	1	02	01	H6322_003_1	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H6322	003	1	1	02	01	H6322_003_1	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	003	1	1	02	01	H6322_003_1	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	003	1	1	02	01	H6322_003_1	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H6322	003	1	1	02	01	H6322_003_1	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	003	1	1	02	01	H6322_003_1	7			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	003	2	1	02	01	H6322_003_2	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	003	2	1	02	01	H6322_003_2	7			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6322	003	2	1	02	01	H6322_003_2	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H6322	003	2	1	02	01	H6322_003_2	7			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	003	2	1	02	01	H6322_003_2	7			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H6322	003	2	1	02	01	H6322_003_2	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H6322	003	2	1	02	01	H6322_003_2	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H6322	003	2	1	02	01	H6322_003_2	7			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6328	001	0	1	04	01	H6328_001_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	001	0	1	04	01	H6328_001_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6328	001	0	1	04	01	H6328_001_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	16.00																			8.00	16.00	16.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	001	0	1	04	01	H6328_001_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	16.00																			8.00	16.00	16.00																8.00				8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6328	001	0	1	04	01	H6328_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	43.00	86.00	86.00																			43.00	86.00	86.00																43.00				43.00		1.43			1.43			1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H6328	001	0	1	04	01	H6328_001_0	11			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	43.00	86.00	86.00																			43.00	86.00	86.00																43.00				43.00		1.43			1.43			1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6328	001	0	1	04	01	H6328_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	92.00	184.00	184.00																			92.00	184.00	184.00																92.00				92.00		3.07			3.07			2.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6328	001	0	1	04	01	H6328_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	002	0	1	04	01	H6328_002_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	4.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	002	0	1	04	01	H6328_002_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	4.00																			0.00	0.00	0.00																2.00				2.00		0.07			0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6328	002	0	1	04	01	H6328_002_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	12.00	24.00	24.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	002	0	1	04	01	H6328_002_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	12.00	24.00	24.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6328	002	0	1	04	01	H6328_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	90.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H6328	002	0	1	04	01	H6328_002_0	11			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	90.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6328	002	0	1	04	01	H6328_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	97.00	194.00	194.00																			97.00	194.00	194.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6328	002	0	1	04	01	H6328_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	003	0	1	04	01	H6328_003_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	8.00																			0.00	0.00	0.00																4.00				4.00		0.13			0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	003	0	1	04	01	H6328_003_0	11			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	4.00	8.00	8.00																			0.00	0.00	0.00																4.00				4.00		0.13			0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6328	003	0	1	04	01	H6328_003_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	12.00	24.00	24.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6328	003	0	1	04	01	H6328_003_0	11			Generic	4	11	1	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	12.00	24.00	24.00																			12.00	24.00	24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6328	003	0	1	04	01	H6328_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H6328	003	0	1	04	01	H6328_003_0	11			Preferred Brand	4	11	1	2	3	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6328	003	0	1	04	01	H6328_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6328	003	0	1	04	01	H6328_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6348	002	0	1	04	01	H6348_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6348	002	0	1	04	01	H6348_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6348	002	0	1	04	01	H6348_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6348	002	0	1	04	01	H6348_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											74.81	50	50	50				74.81	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6348	002	0	1	04	01	H6348_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6348	002	0	1	04	01	H6348_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6348	007	0	1	04	01	H6348_007_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6348	007	0	1	04	01	H6348_007_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6348	007	0	1	04	01	H6348_007_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6348	007	0	1	04	01	H6348_007_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.25	50	50	50				92.25	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6348	007	0	1	04	01	H6348_007_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6348	007	0	1	04	01	H6348_007_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6351	004	0	1	01	01	H6351_004_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H6351	004	0	1	01	01	H6351_004_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H6351	004	0	1	01	01	H6351_004_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	35.00	70.00	105.00																			30.00	60.00	90.00																35.00				35.00		1.17			1.00			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H6351	004	0	1	01	01	H6351_004_0	5			Non-Preferred Brand	4	10	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			90.00	180.00	270.00																95.00				95.00		3.17			3.00			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6351	004	0	1	01	01	H6351_004_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																											
H6351	004	0	1	01	01	H6351_004_0	5			Select Diabetic Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6379	001	0	1	01	01	H6379_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	0.00					0.00	0.00	0.00											9.00	18.00	0.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6379	001	0	1	01	01	H6379_001_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6379	001	0	1	01	01	H6379_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H6379	001	0	1	01	01	H6379_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6379	001	0	1	01	01	H6379_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											885.56	33						885.56	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6379	002	0	1	01	01	H6379_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6379	002	0	1	01	01	H6379_002_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	50.00					0.00	0.00	0.00											20.00	40.00	50.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6379	002	0	1	01	01	H6379_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H6379	002	0	1	01	01	H6379_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6379	002	0	1	01	01	H6379_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.82	29						589.82	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6408	001	0	1	01	01	H6408_001_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6408	001	0	1	01	01	H6408_001_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6408	001	0	1	01	01	H6408_001_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H6408	001	0	1	01	01	H6408_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6408	001	0	1	01	01	H6408_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6408	001	0	1	01	01	H6408_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	33						950.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6408	002	0	1	01	01	H6408_002_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6408	002	0	1	01	01	H6408_002_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6408	002	0	1	01	01	H6408_002_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					0.00	0.00	0.00																20.00				20.00			0.67	0.33	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	0.00	0.00	0.00				20.00		20.00
H6408	002	0	1	01	01	H6408_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6408	002	0	1	01	01	H6408_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6408	002	0	1	01	01	H6408_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	29						950.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6446	001	0	1	01	01	H6446_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	001	0	1	01	01	H6446_001_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6446	001	0	1	01	01	H6446_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	001	0	1	01	01	H6446_001_0	17			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6446	001	0	1	01	01	H6446_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6446	001	0	1	01	01	H6446_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.77	48	48	48				98.77	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6446	001	0	1	01	01	H6446_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6446	001	0	1	01	01	H6446_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	001	0	1	01	01	H6446_001_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H6446	010	0	1	01	01	H6446_010_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	010	0	1	01	01	H6446_010_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	010	0	1	01	01	H6446_010_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6446	010	0	1	01	01	H6446_010_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.01	48	48	48				99.01	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6446	010	0	1	01	01	H6446_010_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6446	010	0	1	01	01	H6446_010_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	017	0	1	01	01	H6446_017_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	017	0	1	01	01	H6446_017_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2	3															
H6446	017	0	1	01	01	H6446_017_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	017	0	1	01	01	H6446_017_0	17			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6446	017	0	1	01	01	H6446_017_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6446	017	0	1	01	01	H6446_017_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.61	38	38	38				99.61	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6446	017	0	1	01	01	H6446_017_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6446	017	0	1	01	01	H6446_017_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H6446	017	0	1	01	01	H6446_017_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	1																
H6453	011	0	1	02	01	H6453_011_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	011	0	1	02	01	H6453_011_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	011	0	1	02	01	H6453_011_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	011	0	1	02	01	H6453_011_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	011	0	1	02	01	H6453_011_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H6453	011	0	1	02	01	H6453_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H6453	011	0	1	02	01	H6453_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1102.10	29						659.28	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	1	1	02	01	H6453_013_1	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	1	1	02	01	H6453_013_1	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	1	1	02	01	H6453_013_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	1	1	02	01	H6453_013_1	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	1	1	02	01	H6453_013_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	1	1	02	01	H6453_013_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	1	1	02	01	H6453_013_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1196.75	33						758.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	2	1	02	01	H6453_013_2	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	2	1	02	01	H6453_013_2	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	2	1	02	01	H6453_013_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	2	1	02	01	H6453_013_2	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	2	1	02	01	H6453_013_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	2	1	02	01	H6453_013_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	2	1	02	01	H6453_013_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1196.75	33						758.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	3	1	02	01	H6453_013_3	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	3	1	02	01	H6453_013_3	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	3	1	02	01	H6453_013_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	3	1	02	01	H6453_013_3	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	3	1	02	01	H6453_013_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	3	1	02	01	H6453_013_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	3	1	02	01	H6453_013_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1196.75	33						758.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	4	1	02	01	H6453_013_4	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	4	1	02	01	H6453_013_4	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	4	1	02	01	H6453_013_4	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	4	1	02	01	H6453_013_4	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	4	1	02	01	H6453_013_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	4	1	02	01	H6453_013_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	4	1	02	01	H6453_013_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1196.75	33						758.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	5	1	02	01	H6453_013_5	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	5	1	02	01	H6453_013_5	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	5	1	02	01	H6453_013_5	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	013	5	1	02	01	H6453_013_5	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	013	5	1	02	01	H6453_013_5	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	5	1	02	01	H6453_013_5	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	013	5	1	02	01	H6453_013_5	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1196.75	33						758.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	017	1	1	02	01	H6453_017_1	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	017	1	1	02	01	H6453_017_1	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	017	1	1	02	01	H6453_017_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	017	1	1	02	01	H6453_017_1	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	017	1	1	02	01	H6453_017_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H6453	017	1	1	02	01	H6453_017_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H6453	017	1	1	02	01	H6453_017_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											919.31	33						628.38	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	017	2	1	02	01	H6453_017_2	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	017	2	1	02	01	H6453_017_2	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	017	2	1	02	01	H6453_017_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	017	2	1	02	01	H6453_017_2	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	017	2	1	02	01	H6453_017_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H6453	017	2	1	02	01	H6453_017_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H6453	017	2	1	02	01	H6453_017_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											919.31	33						628.38	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	018	1	1	02	01	H6453_018_1	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	018	1	1	02	01	H6453_018_1	9			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	018	1	1	02	01	H6453_018_1	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	018	1	1	02	01	H6453_018_1	9			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	018	1	1	02	01	H6453_018_1	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	018	1	1	02	01	H6453_018_1	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	018	1	1	02	01	H6453_018_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											790.78	33						413.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	018	2	1	02	01	H6453_018_2	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	018	2	1	02	01	H6453_018_2	9			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	018	2	1	02	01	H6453_018_2	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6453	018	2	1	02	01	H6453_018_2	9			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6453	018	2	1	02	01	H6453_018_2	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	018	2	1	02	01	H6453_018_2	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6453	018	2	1	02	01	H6453_018_2	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											790.78	33						413.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6474	001	0	1	01	01	H6474_001_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6474	001	0	1	01	01	H6474_001_0	7			Preferred Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H6474	001	0	1	01	01	H6474_001_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	8.00		24.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													8.00		24.00						16.00				8.00		8.00
H6474	001	0	1	01	01	H6474_001_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	001	0	1	01	01	H6474_001_0	7			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	100.00		300.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	001	0	1	01	01	H6474_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				542.63	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00												20.00		20.00
H6474	001	0	1	01	01	H6474_001_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6474	001	0	1	01	01	H6474_001_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6474	002	0	1	01	01	H6474_002_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6474	002	0	1	01	01	H6474_002_0	7			Preferred Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H6474	002	0	1	01	01	H6474_002_0	7			Generic	4	01	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31				10.96	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	002	0	1	01	01	H6474_002_0	7			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				122.72	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	002	0	1	01	01	H6474_002_0	7			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				64.13	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	002	0	1	01	01	H6474_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				543.62	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00												20.00		20.00
H6474	002	0	1	01	01	H6474_002_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6474	002	0	1	01	01	H6474_002_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6474	003	0	1	01	01	H6474_003_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6474	003	0	1	01	01	H6474_003_0	7			Preferred Generic	4	01	3	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1		3															
H6474	003	0	1	01	01	H6474_003_0	7			Generic	4	01	1	1	2	1	110		01	100		1	30		100				1	2			100				30		31				8.76	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	003	0	1	01	01	H6474_003_0	7			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				111.92	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	003	0	1	01	01	H6474_003_0	7			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				59.49	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00		60.00						60.00				20.00		20.00
H6474	003	0	1	01	01	H6474_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				503.51	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													20.00												20.00		20.00
H6474	003	0	1	01	01	H6474_003_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6474	003	0	1	01	01	H6474_003_0	7			Select Care Drugs	4	11	1	2	6	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H6502	002	0	1	04	01	H6502_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	002	0	1	04	01	H6502_002_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	0.00											10.00	20.00	0.00				10.00	0.00	0.00				10.00				10.00			0.50	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	002	0	1	04	01	H6502_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6502	002	0	1	04	01	H6502_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	002	0	1	04	01	H6502_002_0	7			Specialty Tier	4	11	1	3	5	1		010	01		010	1				30								30			30		31								100.00			1320.00	33			100.00			1320.00	33									100.00			33			100.00			33			100.00		33		100.00	33		3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	004	0	1	04	01	H6502_004_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	004	0	1	04	01	H6502_004_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	0.00																			10.00	20.00	0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	004	0	1	04	01	H6502_004_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6502	004	0	1	04	01	H6502_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	004	0	1	04	01	H6502_004_0	7			Specialty Tier	4	11	1	3	5	1	010		01	010		1	30								30						30		31	100.00			1320.00	33																	100.00			33															100.00		33		100.00	33	3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	005	0	1	04	01	H6502_005_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	005	0	1	04	01	H6502_005_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	0.00																			10.00	20.00	0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	005	0	1	04	01	H6502_005_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6502	005	0	1	04	01	H6502_005_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6502	005	0	1	04	01	H6502_005_0	7			Specialty Tier	4	11	1	3	5	1	010		01	010		1	30								30						30		31	100.00			1320.00	33																	100.00			33															100.00		33		100.00	33	3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6526	001	0	1	02	01	H6526_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6526	001	0	1	02	01	H6526_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6526	001	0	1	02	01	H6526_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6526	001	0	1	02	01	H6526_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H6526	001	0	1	02	01	H6526_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H6526	001	0	1	02	01	H6526_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H6526	001	0	1	02	01	H6526_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				591.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6526	002	0	1	02	01	H6526_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6526	002	0	1	02	01	H6526_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6526	002	0	1	02	01	H6526_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6526	002	0	1	02	01	H6526_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H6526	002	0	1	02	01	H6526_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H6526	002	0	1	02	01	H6526_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H6526	002	0	1	02	01	H6526_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				702.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6529	001	1	1	01	01	H6529_001_1	8			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								6.00	12.00	18.00					0.00	0.00	0.00					2.00	4.00	0.00																	6.00			6.00			0.20	0.00	0.07			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													6.00	12.00	18.00	0.00	0.00	0.00	2.00	4.00	0.00				6.00		6.00
H6529	001	1	1	01	01	H6529_001_1	8			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								15.00	30.00	45.00					5.00	10.00	15.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.17	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	5.00	10.00	15.00	8.00	16.00	0.00				15.00		15.00
H6529	001	1	1	01	01	H6529_001_1	8			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6529	001	1	1	01	01	H6529_001_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								100.00	200.00	300.00					90.00	180.00	270.00					100.00	200.00	300.00																	100.00			100.00			3.33	3.00	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6529	001	1	1	01	01	H6529_001_1	8			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00									35.00		35.00
H6529	001	1	1	01	01	H6529_001_1	8			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H6529	001	2	1	01	01	H6529_001_2	4			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								6.00	12.00	18.00					0.00	0.00	0.00					2.00	4.00	0.00																	6.00			6.00			0.20	0.00	0.07			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													6.00	12.00	18.00	0.00	0.00	0.00	2.00	4.00	0.00				6.00		6.00
H6529	001	2	1	01	01	H6529_001_2	4			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								15.00	30.00	45.00					5.00	10.00	15.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.17	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	5.00	10.00	15.00	8.00	16.00	0.00				15.00		15.00
H6529	001	2	1	01	01	H6529_001_2	4			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6529	001	2	1	01	01	H6529_001_2	4			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								100.00	200.00	300.00					90.00	180.00	270.00					100.00	200.00	300.00																	100.00			100.00			3.33	3.00	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6529	001	2	1	01	01	H6529_001_2	4			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00									35.00		35.00
H6529	001	2	1	01	01	H6529_001_2	4			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H6529	002	0	1	01	01	H6529_002_0	6			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								6.00	12.00	18.00					0.00	0.00	0.00					2.00	4.00	0.00																	6.00			6.00			0.20	0.00	0.07			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													6.00	12.00	18.00	0.00	0.00	0.00	2.00	4.00	0.00				6.00		6.00
H6529	002	0	1	01	01	H6529_002_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								15.00	30.00	45.00					5.00	10.00	15.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.17	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	5.00	10.00	15.00	8.00	16.00	0.00				15.00		15.00
H6529	002	0	1	01	01	H6529_002_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6529	002	0	1	01	01	H6529_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								100.00	200.00	300.00					90.00	180.00	270.00					100.00	200.00	300.00																	100.00			100.00			3.33	3.00	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6529	002	0	1	01	01	H6529_002_0	6			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00									35.00		35.00
H6529	002	0	1	01	01	H6529_002_0	6			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H6545	001	0	1	04	01	H6545_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6545	001	0	1	04	01	H6545_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6545	001	0	1	04	01	H6545_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H6545	001	0	1	04	01	H6545_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H6545	001	0	1	04	01	H6545_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H6545	001	0	1	04	01	H6545_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6545	001	0	1	04	01	H6545_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H6550	003	0	1	01	01	H6550_003_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	003	0	1	01	01	H6550_003_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					9.00	18.00	27.00											14.00	28.00	42.00				9.00	18.00	0.00				14.00				14.00			0.47	0.30		0.47	0.30	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	003	0	1	01	01	H6550_003_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6550	003	0	1	01	01	H6550_003_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											95.15	50	50	50				95.15	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6550	003	0	1	01	01	H6550_003_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6550	003	0	1	01	01	H6550_003_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	006	0	1	01	01	H6550_006_0	18			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	006	0	1	01	01	H6550_006_0	18			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	006	0	1	01	01	H6550_006_0	18			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H6550	006	0	1	01	01	H6550_006_0	18			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.39	44	44	44				98.39	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6550	006	0	1	01	01	H6550_006_0	18			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6550	006	0	1	01	01	H6550_006_0	18			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	007	0	1	01	01	H6550_007_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	007	0	1	01	01	H6550_007_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					9.00	18.00	27.00											14.00	28.00	42.00				9.00	18.00	0.00				14.00				14.00			0.47	0.30		0.47	0.30	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6550	007	0	1	01	01	H6550_007_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6550	007	0	1	01	01	H6550_007_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.67	50	50	50				84.67	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6550	007	0	1	01	01	H6550_007_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6550	007	0	1	01	01	H6550_007_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6586	001	0	1	04	01	H6586_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6586	001	0	1	04	01	H6586_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6586	001	0	1	04	01	H6586_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	25.00				10.00		10.00
H6586	001	0	1	04	01	H6586_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6586	001	0	1	04	01	H6586_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	001	0	1	04	01	H6586_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	001	0	1	04	01	H6586_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6586	002	0	1	04	01	H6586_002_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6586	002	0	1	04	01	H6586_002_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6586	002	0	1	04	01	H6586_002_0	12			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	25.00				10.00		10.00
H6586	002	0	1	04	01	H6586_002_0	12			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6586	002	0	1	04	01	H6586_002_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	002	0	1	04	01	H6586_002_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	002	0	1	04	01	H6586_002_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6586	003	0	1	04	01	H6586_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6586	003	0	1	04	01	H6586_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6586	003	0	1	04	01	H6586_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6586	003	0	1	04	01	H6586_003_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6586	003	0	1	04	01	H6586_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	003	0	1	04	01	H6586_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	003	0	1	04	01	H6586_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6586	006	0	1	04	01	H6586_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6586	006	0	1	04	01	H6586_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6586	006	0	1	04	01	H6586_006_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H6586	006	0	1	04	01	H6586_006_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H6586	006	0	1	04	01	H6586_006_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	006	0	1	04	01	H6586_006_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6586	006	0	1	04	01	H6586_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6594	001	0	1	04	01	H6594_001_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	001	0	1	04	01	H6594_001_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	001	0	1	04	01	H6594_001_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6594	001	0	1	04	01	H6594_001_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.32	50	50	50				92.32	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6594	001	0	1	04	01	H6594_001_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6594	001	0	1	04	01	H6594_001_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	002	0	1	04	01	H6594_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	002	0	1	04	01	H6594_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	002	0	1	04	01	H6594_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6594	002	0	1	04	01	H6594_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											90.60	50	50	50				90.60	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6594	002	0	1	04	01	H6594_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6594	002	0	1	04	01	H6594_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	002	0	1	04	01	H6594_002_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H6594	003	0	1	04	01	H6594_003_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	003	0	1	04	01	H6594_003_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	003	0	1	04	01	H6594_003_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H6594	003	0	1	04	01	H6594_003_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.72	47	47	47				98.72	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6594	003	0	1	04	01	H6594_003_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6594	003	0	1	04	01	H6594_003_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	004	0	1	04	01	H6594_004_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	004	0	1	04	01	H6594_004_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6594	004	0	1	04	01	H6594_004_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H6594	004	0	1	04	01	H6594_004_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.77	46	46	46				98.77	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6594	004	0	1	04	01	H6594_004_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6594	004	0	1	04	01	H6594_004_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	001	0	1	04	01	H6605_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	001	0	1	04	01	H6605_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	001	0	1	04	01	H6605_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6605	001	0	1	04	01	H6605_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.40	48	48	48				99.40	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6605	001	0	1	04	01	H6605_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H6605	001	0	1	04	01	H6605_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	003	0	1	04	01	H6605_003_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	003	0	1	04	01	H6605_003_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	003	0	1	04	01	H6605_003_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H6605	003	0	1	04	01	H6605_003_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.77	41	41	41				99.77	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6605	003	0	1	04	01	H6605_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6605	003	0	1	04	01	H6605_003_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	004	0	1	04	01	H6605_004_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	004	0	1	04	01	H6605_004_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6605	004	0	1	04	01	H6605_004_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6605	004	0	1	04	01	H6605_004_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.10	50	50	50				92.10	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6605	004	0	1	04	01	H6605_004_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6605	004	0	1	04	01	H6605_004_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6622	001	0	1	01	01	H6622_001_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	001	0	1	01	01	H6622_001_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	001	0	1	01	01	H6622_001_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	001	0	1	01	01	H6622_001_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	001	0	1	01	01	H6622_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	001	0	1	01	01	H6622_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	001	0	1	01	01	H6622_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	004	0	1	01	01	H6622_004_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	004	0	1	01	01	H6622_004_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	004	0	1	01	01	H6622_004_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	004	0	1	01	01	H6622_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	004	0	1	01	01	H6622_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	007	0	1	01	01	H6622_007_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	007	0	1	01	01	H6622_007_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	007	0	1	01	01	H6622_007_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H6622	007	0	1	01	01	H6622_007_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	007	0	1	01	01	H6622_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	007	0	1	01	01	H6622_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	007	0	1	01	01	H6622_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	010	0	1	02	01	H6622_010_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	010	0	1	02	01	H6622_010_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	010	0	1	02	01	H6622_010_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	010	0	1	02	01	H6622_010_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	010	0	1	02	01	H6622_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	013	0	1	02	01	H6622_013_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	013	0	1	02	01	H6622_013_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	013	0	1	02	01	H6622_013_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	013	0	1	02	01	H6622_013_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	013	0	1	02	01	H6622_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	013	0	1	02	01	H6622_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	013	0	1	02	01	H6622_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	014	0	1	02	01	H6622_014_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	014	0	1	02	01	H6622_014_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	014	0	1	02	01	H6622_014_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	014	0	1	02	01	H6622_014_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	014	0	1	02	01	H6622_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	014	0	1	02	01	H6622_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	014	0	1	02	01	H6622_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	017	0	1	01	01	H6622_017_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H6622	017	0	1	01	01	H6622_017_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H6622	017	0	1	01	01	H6622_017_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	017	0	1	01	01	H6622_017_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	017	0	1	01	01	H6622_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H6622	017	0	1	01	01	H6622_017_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									11.00		33.00				7.00		0.00				7.00				7.00		0.23				0.37	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00		21.00				11.00		33.00	7.00		0.00	7.00		7.00
H6622	019	0	1	01	01	H6622_019_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	1.00		3.00																									10.00		30.00				1.00		0.00				1.00				1.00		0.03				0.33	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				10.00		30.00	1.00		0.00	1.00		1.00
H6622	019	0	1	01	01	H6622_019_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	4.00		12.00																									20.00		60.00				4.00		0.00				4.00				4.00		0.13				0.67	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				20.00		60.00	4.00		0.00	4.00		4.00
H6622	019	0	1	01	01	H6622_019_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	019	0	1	01	01	H6622_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	019	0	1	01	01	H6622_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	021	1	1	02	01	H6622_021_1	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	021	1	1	02	01	H6622_021_1	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	021	1	1	02	01	H6622_021_1	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	021	1	1	02	01	H6622_021_1	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	021	1	1	02	01	H6622_021_1	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	021	1	1	02	01	H6622_021_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	021	1	1	02	01	H6622_021_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	021	2	1	02	01	H6622_021_2	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	021	2	1	02	01	H6622_021_2	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	021	2	1	02	01	H6622_021_2	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	021	2	1	02	01	H6622_021_2	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	021	2	1	02	01	H6622_021_2	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	021	2	1	02	01	H6622_021_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	021	2	1	02	01	H6622_021_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	022	0	1	02	01	H6622_022_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	022	0	1	02	01	H6622_022_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	022	0	1	02	01	H6622_022_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	022	0	1	02	01	H6622_022_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	022	0	1	02	01	H6622_022_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	022	0	1	02	01	H6622_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	022	0	1	02	01	H6622_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	023	0	1	02	01	H6622_023_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H6622	023	0	1	02	01	H6622_023_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	023	0	1	02	01	H6622_023_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	023	0	1	02	01	H6622_023_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	023	0	1	02	01	H6622_023_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	023	0	1	02	01	H6622_023_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	023	0	1	02	01	H6622_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	025	0	1	02	01	H6622_025_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	025	0	1	02	01	H6622_025_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	025	0	1	02	01	H6622_025_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	025	0	1	02	01	H6622_025_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	025	0	1	02	01	H6622_025_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	026	0	1	02	01	H6622_026_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	026	0	1	02	01	H6622_026_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	026	0	1	02	01	H6622_026_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	026	0	1	02	01	H6622_026_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	026	0	1	02	01	H6622_026_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	028	0	1	01	01	H6622_028_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H6622	028	0	1	01	01	H6622_028_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00
H6622	028	0	1	01	01	H6622_028_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	028	0	1	01	01	H6622_028_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	028	0	1	01	01	H6622_028_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	029	0	1	01	01	H6622_029_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	029	0	1	01	01	H6622_029_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3	3															
H6622	029	0	1	01	01	H6622_029_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	029	0	1	01	01	H6622_029_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	029	0	1	01	01	H6622_029_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	029	0	1	01	01	H6622_029_0	6			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		100				2	2				30		100	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	029	0	1	01	01	H6622_029_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	80.00		240.00																									100.00		300.00				80.00		230.00				80.00				80.00		2.67				3.33	2.67	2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	029	0	1	01	01	H6622_029_0	6			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		100				2	2				30		100	30		31	80.00		240.00																									100.00		300.00				80.00		230.00				80.00				80.00		2.67				3.33	2.67	2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	029	0	1	01	01	H6622_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	029	0	1	01	01	H6622_029_0	6			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	030	0	1	01	01	H6622_030_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	030	0	1	01	01	H6622_030_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6622	030	0	1	01	01	H6622_030_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00
H6622	030	0	1	01	01	H6622_030_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	030	0	1	01	01	H6622_030_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	030	0	1	01	01	H6622_030_0	5			Preferred Brand	4	11	1	2	3	3	110		01		110	1	30		100				2	2				30		100	30		31	40.00		120.00																									47.00		141.00				40.00		110.00				40.00				40.00		1.33				1.57	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	030	0	1	01	01	H6622_030_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	80.00		240.00																									100.00		300.00				80.00		230.00				80.00				80.00		2.67				3.33	2.67	2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	030	0	1	01	01	H6622_030_0	5			Non-Preferred Drug	4	11	1	2	4	3	110		01		110	1	30		100				2	2				30		100	30		31	80.00		240.00																									100.00		300.00				80.00		230.00				80.00				80.00		2.67				3.33	2.67	2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	030	0	1	01	01	H6622_030_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	030	0	1	01	01	H6622_030_0	5			Specialty Tier	4	11	1	1	5	3	010		01		010	1	30											30			30		31					15																										15						15					15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	3																
H6622	032	0	1	01	01	H6622_032_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	032	0	1	01	01	H6622_032_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	032	0	1	01	01	H6622_032_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	032	0	1	01	01	H6622_032_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	032	0	1	01	01	H6622_032_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	032	0	1	01	01	H6622_032_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	032	0	1	01	01	H6622_032_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	033	0	1	01	01	H6622_033_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	033	0	1	01	01	H6622_033_0	6			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	033	0	1	01	01	H6622_033_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	033	0	1	01	01	H6622_033_0	6			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	033	0	1	01	01	H6622_033_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	033	0	1	01	01	H6622_033_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	033	0	1	01	01	H6622_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	035	0	1	01	01	H6622_035_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	035	0	1	01	01	H6622_035_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	035	0	1	01	01	H6622_035_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	035	0	1	01	01	H6622_035_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	035	0	1	01	01	H6622_035_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	035	0	1	01	01	H6622_035_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	035	0	1	01	01	H6622_035_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	036	0	1	01	01	H6622_036_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	036	0	1	01	01	H6622_036_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	036	0	1	01	01	H6622_036_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	036	0	1	01	01	H6622_036_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	036	0	1	01	01	H6622_036_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	036	0	1	01	01	H6622_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	036	0	1	01	01	H6622_036_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	037	0	1	01	01	H6622_037_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	037	0	1	01	01	H6622_037_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	037	0	1	01	01	H6622_037_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	037	0	1	01	01	H6622_037_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	037	0	1	01	01	H6622_037_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	037	0	1	01	01	H6622_037_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	037	0	1	01	01	H6622_037_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	047	0	1	01	01	H6622_047_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	047	0	1	01	01	H6622_047_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	047	0	1	01	01	H6622_047_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	42.00		126.00																									47.00		141.00				42.00		116.00				42.00				42.00		1.40				1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	047	0	1	01	01	H6622_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	90.00		270.00																									100.00		300.00				90.00		260.00				90.00				90.00		3.00				3.33	3.00	2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	047	0	1	01	01	H6622_047_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	052	0	1	01	01	H6622_052_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	052	0	1	01	01	H6622_052_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	052	0	1	01	01	H6622_052_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	052	0	1	01	01	H6622_052_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	052	0	1	01	01	H6622_052_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	052	0	1	01	01	H6622_052_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	052	0	1	01	01	H6622_052_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	054	0	1	01	01	H6622_054_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	054	0	1	01	01	H6622_054_0	6			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	054	0	1	01	01	H6622_054_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	054	0	1	01	01	H6622_054_0	6			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	054	0	1	01	01	H6622_054_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	054	0	1	01	01	H6622_054_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	054	0	1	01	01	H6622_054_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	055	0	1	01	01	H6622_055_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	055	0	1	01	01	H6622_055_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	055	0	1	01	01	H6622_055_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	055	0	1	01	01	H6622_055_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	055	0	1	01	01	H6622_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	055	0	1	01	01	H6622_055_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	055	0	1	01	01	H6622_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	056	0	1	01	01	H6622_056_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	056	0	1	01	01	H6622_056_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	056	0	1	01	01	H6622_056_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	056	0	1	01	01	H6622_056_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	056	0	1	01	01	H6622_056_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	056	0	1	01	01	H6622_056_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	056	0	1	01	01	H6622_056_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	057	0	1	02	01	H6622_057_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	057	0	1	02	01	H6622_057_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	057	0	1	02	01	H6622_057_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	057	0	1	02	01	H6622_057_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	057	0	1	02	01	H6622_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	060	0	1	02	01	H6622_060_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	060	0	1	02	01	H6622_060_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	060	0	1	02	01	H6622_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	060	0	1	02	01	H6622_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	97.00		291.00																									100.00		300.00				97.00		281.00				97.00				97.00		3.23				3.33	3.23	3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	060	0	1	02	01	H6622_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	061	0	1	02	01	H6622_061_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	061	0	1	02	01	H6622_061_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	061	0	1	02	01	H6622_061_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	061	0	1	02	01	H6622_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	061	0	1	02	01	H6622_061_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	063	0	1	01	01	H6622_063_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	063	0	1	01	01	H6622_063_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	063	0	1	01	01	H6622_063_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	063	0	1	01	01	H6622_063_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	063	0	1	01	01	H6622_063_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	063	0	1	01	01	H6622_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	063	0	1	01	01	H6622_063_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	066	0	1	01	01	H6622_066_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	066	0	1	01	01	H6622_066_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	066	0	1	01	01	H6622_066_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	066	0	1	01	01	H6622_066_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	066	0	1	01	01	H6622_066_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	066	0	1	01	01	H6622_066_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	066	0	1	01	01	H6622_066_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	071	0	1	01	01	H6622_071_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	071	0	1	01	01	H6622_071_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6622	071	0	1	01	01	H6622_071_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	071	0	1	01	01	H6622_071_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6622	071	0	1	01	01	H6622_071_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	071	0	1	01	01	H6622_071_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	071	0	1	01	01	H6622_071_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H6622	071	0	1	01	01	H6622_071_0	7			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H6622	073	0	1	02	01	H6622_073_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	073	0	1	02	01	H6622_073_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	073	0	1	02	01	H6622_073_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	073	0	1	02	01	H6622_073_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H6622	073	0	1	02	01	H6622_073_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	073	0	1	02	01	H6622_073_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	073	0	1	02	01	H6622_073_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	075	0	1	01	01	H6622_075_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	075	0	1	01	01	H6622_075_0	5			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	075	0	1	01	01	H6622_075_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H6622	075	0	1	01	01	H6622_075_0	5			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6622	075	0	1	01	01	H6622_075_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	075	0	1	01	01	H6622_075_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	075	0	1	01	01	H6622_075_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	081	0	1	01	01	H6622_081_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	081	0	1	01	01	H6622_081_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	081	0	1	01	01	H6622_081_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	081	0	1	01	01	H6622_081_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	081	0	1	01	01	H6622_081_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	082	0	1	01	01	H6622_082_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	082	0	1	01	01	H6622_082_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	082	0	1	01	01	H6622_082_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	082	0	1	01	01	H6622_082_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	082	0	1	01	01	H6622_082_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	083	0	1	01	01	H6622_083_0	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	083	0	1	01	01	H6622_083_0	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	083	0	1	01	01	H6622_083_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	083	0	1	01	01	H6622_083_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	083	0	1	01	01	H6622_083_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	084	0	1	01	01	H6622_084_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	084	0	1	01	01	H6622_084_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6622	084	0	1	01	01	H6622_084_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H6622	084	0	1	01	01	H6622_084_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6622	084	0	1	01	01	H6622_084_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	084	0	1	01	01	H6622_084_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	084	0	1	01	01	H6622_084_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00			35.00			35.00		35.00
H6622	084	0	1	01	01	H6622_084_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
H6622	085	0	1	01	01	H6622_085_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H6622	085	0	1	01	01	H6622_085_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
H6622	085	0	1	01	01	H6622_085_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	085	0	1	01	01	H6622_085_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	085	0	1	01	01	H6622_085_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6622	088	0	1	02	01	H6622_088_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H6622	088	0	1	02	01	H6622_088_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H6622	088	0	1	02	01	H6622_088_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	088	0	1	02	01	H6622_088_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H6622	088	0	1	02	01	H6622_088_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H6672	003	0	1	01	01	H6672_003_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6672	003	0	1	01	01	H6672_003_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	50.00					0.00	0.00	0.00											20.00	40.00	50.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6672	003	0	1	01	01	H6672_003_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H6672	003	0	1	01	01	H6672_003_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6672	003	0	1	01	01	H6672_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											592.71	29						592.71	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6672	005	0	1	01	01	H6672_005_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6672	005	0	1	01	01	H6672_005_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	42.50					0.00	0.00	0.00											17.00	34.00	42.50				0.00	0.00	0.00				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6672	005	0	1	01	01	H6672_005_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H6672	005	0	1	01	01	H6672_005_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6672	005	0	1	01	01	H6672_005_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1019.33	33						1019.33	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6678	003	0	1	01	01	H6678_003_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6678	003	0	1	01	01	H6678_003_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6678	003	0	1	01	01	H6678_003_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6678	003	0	1	01	01	H6678_003_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.81	50	50	50				92.81	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6678	003	0	1	01	01	H6678_003_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6678	003	0	1	01	01	H6678_003_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6678	004	0	1	01	01	H6678_004_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6678	004	0	1	01	01	H6678_004_0	16			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6678	004	0	1	01	01	H6678_004_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6678	004	0	1	01	01	H6678_004_0	16			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6678	004	0	1	01	01	H6678_004_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6678	004	0	1	01	01	H6678_004_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											94.31	50	50	50				94.31	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6678	004	0	1	01	01	H6678_004_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6678	004	0	1	01	01	H6678_004_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6678	004	0	1	01	01	H6678_004_0	16			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H6706	001	0	1	02	01	H6706_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6706	001	0	1	02	01	H6706_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6706	001	0	1	02	01	H6706_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6706	001	0	1	02	01	H6706_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H6706	001	0	1	02	01	H6706_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H6706	001	0	1	02	01	H6706_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H6706	001	0	1	02	01	H6706_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				535.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6713	001	0	1	04	01	H6713_001_0	10			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6713	001	0	1	04	01	H6713_001_0	10			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6713	001	0	1	04	01	H6713_001_0	10			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6713	001	0	1	04	01	H6713_001_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6713	001	0	1	04	01	H6713_001_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.20	47	47	47				99.20	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6713	001	0	1	04	01	H6713_001_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6713	001	0	1	04	01	H6713_001_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6713	001	0	1	04	01	H6713_001_0	10			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H6713	002	0	1	04	01	H6713_002_0	21			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6713	002	0	1	04	01	H6713_002_0	21			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6713	002	0	1	04	01	H6713_002_0	21			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6713	002	0	1	04	01	H6713_002_0	21			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6713	002	0	1	04	01	H6713_002_0	21			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.61	50	50	50				99.61	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6713	002	0	1	04	01	H6713_002_0	21			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6713	002	0	1	04	01	H6713_002_0	21			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6713	002	0	1	04	01	H6713_002_0	21			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H6723	001	1	1	01	01	H6723_001_1	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	1	1	01	01	H6723_001_1	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	001	1	1	01	01	H6723_001_1	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.17		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	1	1	01	01	H6723_001_1	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.17		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	001	1	1	01	01	H6723_001_1	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	001	1	1	01	01	H6723_001_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.78	50	50	50				65.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	1	1	01	01	H6723_001_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	2	1	01	01	H6723_001_2	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	2	1	01	01	H6723_001_2	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	001	2	1	01	01	H6723_001_2	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.17		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	2	1	01	01	H6723_001_2	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.17		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	001	2	1	01	01	H6723_001_2	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	001	2	1	01	01	H6723_001_2	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.78	50	50	50				65.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	2	1	01	01	H6723_001_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	3	1	01	01	H6723_001_3	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	3	1	01	01	H6723_001_3	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	001	3	1	01	01	H6723_001_3	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.17		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	3	1	01	01	H6723_001_3	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.17		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	001	3	1	01	01	H6723_001_3	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	001	3	1	01	01	H6723_001_3	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.78	50	50	50				65.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	001	3	1	01	01	H6723_001_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	1	1	01	01	H6723_002_1	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	1	1	01	01	H6723_002_1	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	002	1	1	01	01	H6723_002_1	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	1	1	01	01	H6723_002_1	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	002	1	1	01	01	H6723_002_1	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	002	1	1	01	01	H6723_002_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.10	50	50	50				58.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	1	1	01	01	H6723_002_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	2	1	01	01	H6723_002_2	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	2	1	01	01	H6723_002_2	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	002	2	1	01	01	H6723_002_2	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	2	1	01	01	H6723_002_2	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	002	2	1	01	01	H6723_002_2	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	002	2	1	01	01	H6723_002_2	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.10	50	50	50				58.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	2	1	01	01	H6723_002_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	3	1	01	01	H6723_002_3	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	3	1	01	01	H6723_002_3	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	002	3	1	01	01	H6723_002_3	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	3	1	01	01	H6723_002_3	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	002	3	1	01	01	H6723_002_3	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	002	3	1	01	01	H6723_002_3	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.10	50	50	50				58.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	002	3	1	01	01	H6723_002_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	1	1	01	01	H6723_003_1	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	1	1	01	01	H6723_003_1	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	003	1	1	01	01	H6723_003_1	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	1	1	01	01	H6723_003_1	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	003	1	1	01	01	H6723_003_1	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	003	1	1	01	01	H6723_003_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.92	50	50	50				45.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	1	1	01	01	H6723_003_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	2	1	01	01	H6723_003_2	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	2	1	01	01	H6723_003_2	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	003	2	1	01	01	H6723_003_2	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	2	1	01	01	H6723_003_2	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	003	2	1	01	01	H6723_003_2	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	003	2	1	01	01	H6723_003_2	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.92	50	50	50				45.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	2	1	01	01	H6723_003_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	3	1	01	01	H6723_003_3	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	3	1	01	01	H6723_003_3	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	12.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.17	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	003	3	1	01	01	H6723_003_3	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	3	1	01	01	H6723_003_3	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	003	3	1	01	01	H6723_003_3	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	003	3	1	01	01	H6723_003_3	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.92	50	50	50				45.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	003	3	1	01	01	H6723_003_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												32							32												32						32					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	1	1	01	01	H6723_005_1	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	1	1	01	01	H6723_005_1	10			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	005	1	1	01	01	H6723_005_1	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	1	1	01	01	H6723_005_1	10			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	005	1	1	01	01	H6723_005_1	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	005	1	1	01	01	H6723_005_1	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.02	50	50	50				60.95	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	1	1	01	01	H6723_005_1	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	2	1	01	01	H6723_005_2	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	2	1	01	01	H6723_005_2	10			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	005	2	1	01	01	H6723_005_2	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	2	1	01	01	H6723_005_2	10			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6723	005	2	1	01	01	H6723_005_2	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	005	2	1	01	01	H6723_005_2	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.02	50	50	50				60.95	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	005	2	1	01	01	H6723_005_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6723	006	6	1	01	01	H6723_006_6	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					0.00	0.00	0.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	6	1	01	01	H6723_006_6	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					0.00	0.00	0.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6723	006	6	1	01	01	H6723_006_6	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					0.00	0.00	0.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.00		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	6	1	01	01	H6723_006_6	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					0.00	0.00	0.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.00		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6723	006	6	1	01	01	H6723_006_6	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	006	6	1	01	01	H6723_006_6	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.87	50	50	50				63.75	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	6	1	01	01	H6723_006_6	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	6	1	01	01	H6723_006_6	12			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	6	1	01	01	H6723_006_6	12			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6723	006	7	1	01	01	H6723_006_7	12			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					0.00	0.00	0.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	7	1	01	01	H6723_006_7	12			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					0.00	0.00	0.00											11.00	22.00	28.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.37	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6723	006	7	1	01	01	H6723_006_7	12			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					0.00	0.00	0.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.00		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	7	1	01	01	H6723_006_7	12			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								16.00	32.00	40.00					0.00	0.00	0.00											15.00	30.00	38.00				0.00	0.00	0.00				16.00				16.00			0.53	0.00		0.50	0.00	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6723	006	7	1	01	01	H6723_006_7	12			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	132.00					42.00	84.00	118.00											45.00	90.00	130.00				40.00	80.00	110.00				47.00				47.00			1.57	1.40		1.50	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6723	006	7	1	01	01	H6723_006_7	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.87	50	50	50				63.75	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	7	1	01	01	H6723_006_7	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	7	1	01	01	H6723_006_7	12			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6723	006	7	1	01	01	H6723_006_7	12			Select Care Drugs	4	01	1	2	6	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	20.00					0.00	0.00	0.00											7.00	14.00	18.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6727	001	0	1	04	01	H6727_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H6727	001	0	1	04	01	H6727_001_0	6			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		20.00
H6727	001	0	1	04	01	H6727_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	116.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6727	001	0	1	04	01	H6727_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	275.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6727	001	0	1	04	01	H6727_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6743	001	0	1	04	01	H6743_001_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	7.00		14.00																					14.00																7.00				7.00		0.23						0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	001	0	1	04	01	H6743_001_0	12			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	20.00		40.00																					40.00																20.00				20.00		0.65						0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	001	0	1	04	01	H6743_001_0	12			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	45.00		90.00																					90.00																45.00				45.00		1.45						1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H6743	001	0	1	04	01	H6743_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	95.00		190.00																					190.00																95.00				95.00		3.06						2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	001	0	1	04	01	H6743_001_0	12			Specialty Tier	4	10	1	1	5	1	010		01	000		1	31														31		34					28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	001	0	1	04	01	H6743_001_0	12			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6743	007	0	1	04	01	H6743_007_0	11			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	007	0	1	04	01	H6743_007_0	11			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	007	0	1	04	01	H6743_007_0	11			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H6743	007	0	1	04	01	H6743_007_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	007	0	1	04	01	H6743_007_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	007	0	1	04	01	H6743_007_0	11			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6743	023	1	1	04	01	H6743_023_1	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	1	1	04	01	H6743_023_1	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	1	1	04	01	H6743_023_1	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H6743	023	1	1	04	01	H6743_023_1	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	1	1	04	01	H6743_023_1	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	1	1	04	01	H6743_023_1	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6743	023	3	1	04	01	H6743_023_3	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	3	1	04	01	H6743_023_3	12			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	3	1	04	01	H6743_023_3	12			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H6743	023	3	1	04	01	H6743_023_3	12			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	3	1	04	01	H6743_023_3	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	023	3	1	04	01	H6743_023_3	12			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6743	025	0	1	04	01	H6743_025_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	025	0	1	04	01	H6743_025_0	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	025	0	1	04	01	H6743_025_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H6743	025	0	1	04	01	H6743_025_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	025	0	1	04	01	H6743_025_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	025	0	1	04	01	H6743_025_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6743	026	0	1	04	01	H6743_026_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	026	0	1	04	01	H6743_026_0	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	026	0	1	04	01	H6743_026_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H6743	026	0	1	04	01	H6743_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	026	0	1	04	01	H6743_026_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6743	026	0	1	04	01	H6743_026_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H6750	005	0	1	01	01	H6750_005_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00
H6750	005	0	1	01	01	H6750_005_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					10.00	20.00	20.00																20.00				10.00			0.67	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	10.00	20.00	30.00	10.00	20.00	20.00				20.00		10.00
H6750	005	0	1	01	01	H6750_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6750	005	0	1	01	01	H6750_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6750	005	0	1	01	01	H6750_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	005	0	1	01	01	H6750_005_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	005	0	1	01	01	H6750_005_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H6750	012	1	1	01	01	H6750_012_1	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00
H6750	012	1	1	01	01	H6750_012_1	8			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	24.00					8.00	16.00	16.00																20.00				8.00			0.67	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	8.00	16.00	24.00	8.00	16.00	16.00				20.00		8.00
H6750	012	1	1	01	01	H6750_012_1	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6750	012	1	1	01	01	H6750_012_1	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6750	012	1	1	01	01	H6750_012_1	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	012	1	1	01	01	H6750_012_1	8			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	012	1	1	01	01	H6750_012_1	8			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H6750	012	2	1	01	01	H6750_012_2	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00
H6750	012	2	1	01	01	H6750_012_2	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	24.00					8.00	16.00	16.00																20.00				8.00			0.67	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	8.00	16.00	24.00	8.00	16.00	16.00				20.00		8.00
H6750	012	2	1	01	01	H6750_012_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6750	012	2	1	01	01	H6750_012_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6750	012	2	1	01	01	H6750_012_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	012	2	1	01	01	H6750_012_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	012	2	1	01	01	H6750_012_2	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H6750	013	0	1	01	01	H6750_013_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00
H6750	013	0	1	01	01	H6750_013_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	24.00					8.00	16.00	16.00																20.00				8.00			0.67	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	8.00	16.00	24.00	8.00	16.00	16.00				20.00		8.00
H6750	013	0	1	01	01	H6750_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6750	013	0	1	01	01	H6750_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6750	013	0	1	01	01	H6750_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	013	0	1	01	01	H6750_013_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	013	0	1	01	01	H6750_013_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H6750	014	0	1	02	01	H6750_014_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00
H6750	014	0	1	02	01	H6750_014_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					8.00	16.00	24.00					8.00	16.00	16.00																20.00				8.00			0.67	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	8.00	16.00	24.00	8.00	16.00	16.00				20.00		8.00
H6750	014	0	1	02	01	H6750_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6750	014	0	1	02	01	H6750_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H6750	014	0	1	02	01	H6750_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	014	0	1	02	01	H6750_014_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H6750	014	0	1	02	01	H6750_014_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H6813	001	0	1	04	01	H6813_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6813	001	0	1	04	01	H6813_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6813	001	0	1	04	01	H6813_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H6813	001	0	1	04	01	H6813_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H6813	001	0	1	04	01	H6813_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6813	001	0	1	04	01	H6813_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	297.00																99.00				99.00		3.30			3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6813	001	0	1	04	01	H6813_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6813	002	0	1	04	01	H6813_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6813	002	0	1	04	01	H6813_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6813	002	0	1	04	01	H6813_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6813	002	0	1	04	01	H6813_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6813	002	0	1	04	01	H6813_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6813	002	0	1	04	01	H6813_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	297.00																99.00				99.00		3.30			3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6813	002	0	1	04	01	H6813_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6815	037	0	1	01	01	H6815_037_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	037	0	1	01	01	H6815_037_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	037	0	1	01	01	H6815_037_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H6815	037	0	1	01	01	H6815_037_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.44	50	50	50				99.44	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6815	037	0	1	01	01	H6815_037_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6815	037	0	1	01	01	H6815_037_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	038	0	1	01	01	H6815_038_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	038	0	1	01	01	H6815_038_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	038	0	1	01	01	H6815_038_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6815	038	0	1	01	01	H6815_038_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.34	50	50	50				88.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6815	038	0	1	01	01	H6815_038_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6815	038	0	1	01	01	H6815_038_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	039	0	1	01	01	H6815_039_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	039	0	1	01	01	H6815_039_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H6815	039	0	1	01	01	H6815_039_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	039	0	1	01	01	H6815_039_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6815	039	0	1	01	01	H6815_039_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.03	50	50	50				84.03	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6815	039	0	1	01	01	H6815_039_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6815	039	0	1	01	01	H6815_039_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6815	039	0	1	01	01	H6815_039_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H6830	001	0	1	04	01	H6830_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6830	001	0	1	04	01	H6830_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6830	001	0	1	04	01	H6830_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6830	001	0	1	04	01	H6830_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.64	50	50	50				85.64	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6830	001	0	1	04	01	H6830_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6830	001	0	1	04	01	H6830_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6832	001	0	1	01	01	H6832_001_0	12			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	001	0	1	01	01	H6832_001_0	12			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	001	0	1	01	01	H6832_001_0	12			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6832	001	0	1	01	01	H6832_001_0	12			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	001	0	1	01	01	H6832_001_0	12			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	002	0	1	01	01	H6832_002_0	11			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	002	0	1	01	01	H6832_002_0	11			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	002	0	1	01	01	H6832_002_0	11			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6832	002	0	1	01	01	H6832_002_0	11			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	002	0	1	01	01	H6832_002_0	11			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6832	003	0	1	02	01	H6832_003_0	8			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6832	003	0	1	02	01	H6832_003_0	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6832	003	0	1	02	01	H6832_003_0	8			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6832	003	0	1	02	01	H6832_003_0	8			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6832	003	0	1	02	01	H6832_003_0	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6832	003	0	1	02	01	H6832_003_0	8			Select Care Drugs	4	11	1	2	6	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H6847	001	0	1	02	01	H6847_001_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6847	001	0	1	02	01	H6847_001_0	11			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6847	001	0	1	02	01	H6847_001_0	11			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6847	001	0	1	02	01	H6847_001_0	11			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6847	001	0	1	02	01	H6847_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1270.70	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H6851	002	0	1	01	01	H6851_002_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H6851	002	0	1	01	01	H6851_002_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		90				1	2	30		90				30		31	10.00		25.00																			0.00		0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		25.00				0.00		0.00				10.00		10.00
H6851	002	0	1	01	01	H6851_002_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				1	2	30		90				30		31	47.00		132.00																			45.00		130.00																47.00				47.00		1.57			1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H6851	002	0	1	01	01	H6851_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				1	2	30		90				30		31	100.00		280.00																			97.00		275.00																100.00				100.00		3.33			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6851	002	0	1	01	01	H6851_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6851	003	0	1	01	01	H6851_003_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H6851	003	0	1	01	01	H6851_003_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		90				1	2	30		90				30		31	5.00		12.00																			0.00		0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		12.00				0.00		0.00				5.00		5.00
H6851	003	0	1	01	01	H6851_003_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				1	2	30		90				30		31	47.00		132.00																			45.00		130.00																47.00				47.00		1.57			1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H6851	003	0	1	01	01	H6851_003_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				1	2	30		90				30		31	100.00		280.00																			97.00		275.00																100.00				100.00		3.33			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6851	003	0	1	01	01	H6851_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6851	004	0	1	01	01	H6851_004_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H6851	004	0	1	01	01	H6851_004_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		90				1	2	30		90				30		31	10.00		25.00																			0.00		0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		25.00				0.00		0.00				10.00		10.00
H6851	004	0	1	01	01	H6851_004_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				1	2	30		90				30		31	47.00		132.00																			45.00		130.00																47.00				47.00		1.57			1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H6851	004	0	1	01	01	H6851_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				1	2	30		90				30		31	100.00		280.00																			97.00		275.00																100.00				100.00		3.33			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6851	004	0	1	01	01	H6851_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6852	001	0	1	01	01	H6852_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6852	001	0	1	01	01	H6852_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6852	001	0	1	01	01	H6852_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6852	001	0	1	01	01	H6852_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H6852	001	0	1	01	01	H6852_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H6852	001	0	1	01	01	H6852_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H6852	001	0	1	01	01	H6852_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H6852	002	0	1	01	01	H6852_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6852	002	0	1	01	01	H6852_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H6852	002	0	1	01	01	H6852_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00				7.00	14.00	17.50				7		7
H6852	002	0	1	01	01	H6852_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H6852	002	0	1	01	01	H6852_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H6852	002	0	1	01	01	H6852_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H6852	002	0	1	01	01	H6852_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H6870	001	0	1	48	05	H6870_001_0	15			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H6870	001	0	1	48	05	H6870_001_0	15			Brand Drugs	4	10		2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H6870	001	0	1	48	05	H6870_001_0	15			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H6874	001	0	1	04	01	H6874_001_0	13			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6874	001	0	1	04	01	H6874_001_0	13			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	12.00	24.00	36.00																			12.00	24.00	24.00																	12.00			12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6874	001	0	1	04	01	H6874_001_0	13			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H6874	001	0	1	04	01	H6874_001_0	13			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31				89.00	50	50	50																		50	50	50																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6874	001	0	1	04	01	H6874_001_0	13			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				3279.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	001	0	1	04	01	H6876_001_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	001	0	1	04	01	H6876_001_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6876	001	0	1	04	01	H6876_001_0	12			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	001	0	1	04	01	H6876_001_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	001	0	1	04	01	H6876_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	001	0	1	04	01	H6876_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	002	0	1	04	01	H6876_002_0	11		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	002	0	1	04	01	H6876_002_0	11		N	Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	002	0	1	04	01	H6876_002_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				121.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	002	0	1	04	01	H6876_002_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				91.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	002	0	1	04	01	H6876_002_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	003	0	1	04	01	H6876_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	003	0	1	04	01	H6876_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6876	003	0	1	04	01	H6876_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	003	0	1	04	01	H6876_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	003	0	1	04	01	H6876_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	003	0	1	04	01	H6876_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	003	0	1	04	01	H6876_003_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	004	0	1	04	01	H6876_004_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	004	0	1	04	01	H6876_004_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6876	004	0	1	04	01	H6876_004_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	15.00	30.00	45.00																			0.00	0.00	0.00																15.00				15.00		0.50			0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	004	0	1	04	01	H6876_004_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	004	0	1	04	01	H6876_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	004	0	1	04	01	H6876_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H6876	005	0	1	04	01	H6876_005_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	005	0	1	04	01	H6876_005_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H6876	005	0	1	04	01	H6876_005_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	005	0	1	04	01	H6876_005_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	005	0	1	04	01	H6876_005_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	005	0	1	04	01	H6876_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	005	0	1	04	01	H6876_005_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	006	0	1	04	01	H6876_006_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H6876	006	0	1	04	01	H6876_006_0	9			Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				10.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	006	0	1	04	01	H6876_006_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				10.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	006	0	1	04	01	H6876_006_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				10.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	006	0	1	04	01	H6876_006_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6876	006	0	1	04	01	H6876_006_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	001	0	1	04	01	H6898_001_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	001	0	1	04	01	H6898_001_0	9			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	001	0	1	04	01	H6898_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	118.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H6898	001	0	1	04	01	H6898_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	001	0	1	04	01	H6898_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				977.84	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	001	0	1	04	01	H6898_001_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	002	0	1	04	01	H6898_002_0	10			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	002	0	1	04	01	H6898_002_0	10			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	002	0	1	04	01	H6898_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	100.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	100.00				35.00		35.00
H6898	002	0	1	04	01	H6898_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	002	0	1	04	01	H6898_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				966.43	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6898	002	0	1	04	01	H6898_002_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6910	001	0	1	01	01	H6910_001_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6910	001	0	1	01	01	H6910_001_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6910	001	0	1	01	01	H6910_001_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					6.00	12.00	18.00					0.00	0.00	0.00																20.00				20.00			0.67	0.20	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	0.00	0.00	0.00				20.00		20.00
H6910	001	0	1	01	01	H6910_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					31.00	62.00	93.00					31.00	62.00	62.00																47.00				47.00			1.57	1.03	1.03			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													31.00	62.00	93.00	31.00	62.00	93.00	31.00	62.00	62.00				31.00		31.00
H6910	001	0	1	01	01	H6910_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					90.00	180.00	270.00					90.00	180.00	180.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6910	001	0	1	01	01	H6910_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	33						950.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6910	005	0	1	01	01	H6910_005_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H6910	005	0	1	01	01	H6910_005_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H6910	005	0	1	01	01	H6910_005_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					0.00	0.00	0.00																20.00				20.00			0.67	0.33	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	0.00	0.00	0.00				20.00		20.00
H6910	005	0	1	01	01	H6910_005_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6910	005	0	1	01	01	H6910_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H6910	005	0	1	01	01	H6910_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	29						950.00	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H6959	002	0	1	01	01	H6959_002_0	8			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6959	002	0	1	01	01	H6959_002_0	8			Generic	4	01	1	2	2	1	111		10			1	30	60	90				1	2								10	31	15.00	30.00	45.00																																						15.00			15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6959	002	0	1	01	01	H6959_002_0	8			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				1	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00										35.00		35.00
H6959	002	0	1	01	01	H6959_002_0	8			Non-Preferred Brand	4	10	1	2	4	1	111		10			1	30	60	90				1	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6959	002	0	1	01	01	H6959_002_0	8			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31					28																																						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H6975	003	0	1	01	01	H6975_003_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6975	003	0	1	01	01	H6975_003_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6975	003	0	1	01	01	H6975_003_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H6975	003	0	1	01	01	H6975_003_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.10	43	43	43				98.10	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6975	003	0	1	01	01	H6975_003_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6975	003	0	1	01	01	H6975_003_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6975	005	0	1	01	01	H6975_005_0	20			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6975	005	0	1	01	01	H6975_005_0	20			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6975	005	0	1	01	01	H6975_005_0	20			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H6975	005	0	1	01	01	H6975_005_0	20			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.99	50	50	50				85.99	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H6975	005	0	1	01	01	H6975_005_0	20			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H6975	005	0	1	01	01	H6975_005_0	20			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H6988	001	0	1	01	01	H6988_001_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H6988	001	0	1	01	01	H6988_001_0	10			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	15.00		45.00																					37.50																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													15.00		45.00						37.50				15.00		15.00
H6988	001	0	1	01	01	H6988_001_0	10			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	47.00		141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H6988	001	0	1	01	01	H6988_001_0	10			Non-Preferred Brand	4	10	1	2	4	1	110		01	100		1	30		90				2	2			90				30		31	100.00		300.00																					250.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H6988	001	0	1	01	01	H6988_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				672.58	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00												35.00		35.00
H7006	003	0	1	04	01	H7006_003_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	003	0	1	04	01	H7006_003_0	7			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	003	0	1	04	01	H7006_003_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	003	0	1	04	01	H7006_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	003	0	1	04	01	H7006_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	003	0	1	04	01	H7006_003_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	007	0	1	04	01	H7006_007_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	007	0	1	04	01	H7006_007_0	7			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	007	0	1	04	01	H7006_007_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	007	0	1	04	01	H7006_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	007	0	1	04	01	H7006_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	007	0	1	04	01	H7006_007_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	010	0	1	04	01	H7006_010_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	010	0	1	04	01	H7006_010_0	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	12.00		24.00																					24.00																12.00				12.00		0.39						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	010	0	1	04	01	H7006_010_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	010	0	1	04	01	H7006_010_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	010	0	1	04	01	H7006_010_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	010	0	1	04	01	H7006_010_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	011	0	1	04	01	H7006_011_0	13			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	011	0	1	04	01	H7006_011_0	13			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	011	0	1	04	01	H7006_011_0	13			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	35.00		70.00																					70.00																35.00				35.00		1.13						1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	011	0	1	04	01	H7006_011_0	13			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	011	0	1	04	01	H7006_011_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	011	0	1	04	01	H7006_011_0	13			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	014	0	1	04	01	H7006_014_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	014	0	1	04	01	H7006_014_0	12			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	12.00		24.00																					24.00																12.00				12.00		0.39						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	014	0	1	04	01	H7006_014_0	12			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	35.00		70.00																					70.00																35.00				35.00		1.13						1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	014	0	1	04	01	H7006_014_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	014	0	1	04	01	H7006_014_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	014	0	1	04	01	H7006_014_0	12			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	015	0	1	04	01	H7006_015_0	12			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	015	0	1	04	01	H7006_015_0	12			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	015	0	1	04	01	H7006_015_0	12			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	35.00		70.00																					70.00																35.00				35.00		1.13						1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	015	0	1	04	01	H7006_015_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	015	0	1	04	01	H7006_015_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	015	0	1	04	01	H7006_015_0	12			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	018	0	1	04	01	H7006_018_0	11			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	018	0	1	04	01	H7006_018_0	11			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	018	0	1	04	01	H7006_018_0	11			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	018	0	1	04	01	H7006_018_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	018	0	1	04	01	H7006_018_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	018	0	1	04	01	H7006_018_0	11			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	019	0	1	04	01	H7006_019_0	11			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	019	0	1	04	01	H7006_019_0	11			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	019	0	1	04	01	H7006_019_0	11			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	019	0	1	04	01	H7006_019_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	019	0	1	04	01	H7006_019_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	019	0	1	04	01	H7006_019_0	11			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7006	020	0	1	04	01	H7006_020_0	11			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	020	0	1	04	01	H7006_020_0	11			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	020	0	1	04	01	H7006_020_0	11			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00						70.00				35.00		35.00
H7006	020	0	1	04	01	H7006_020_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	020	0	1	04	01	H7006_020_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7006	020	0	1	04	01	H7006_020_0	11			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00		0.00						0.00				0.00		0.00
H7020	004	0	1	01	01	H7020_004_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7020	004	0	1	01	01	H7020_004_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7020	004	0	1	01	01	H7020_004_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7020	004	0	1	01	01	H7020_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	004	0	1	01	01	H7020_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	004	0	1	01	01	H7020_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											838.50	33						533.49	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7020	006	0	1	01	01	H7020_006_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7020	006	0	1	01	01	H7020_006_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7020	006	0	1	01	01	H7020_006_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7020	006	0	1	01	01	H7020_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	006	0	1	01	01	H7020_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	006	0	1	01	01	H7020_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											869.81	33						479.60	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7020	008	0	1	01	01	H7020_008_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7020	008	0	1	01	01	H7020_008_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7020	008	0	1	01	01	H7020_008_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H7020	008	0	1	01	01	H7020_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	008	0	1	01	01	H7020_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	008	0	1	01	01	H7020_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											816.69	33						554.26	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7020	009	0	1	01	01	H7020_009_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7020	009	0	1	01	01	H7020_009_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7020	009	0	1	01	01	H7020_009_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7020	009	0	1	01	01	H7020_009_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	009	0	1	01	01	H7020_009_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7020	009	0	1	01	01	H7020_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											838.86	33						607.79	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7028	001	0	1	04	01	H7028_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7028	001	0	1	04	01	H7028_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7028	001	0	1	04	01	H7028_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7028	001	0	1	04	01	H7028_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7028	001	0	1	04	01	H7028_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7028	001	0	1	04	01	H7028_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7028	001	0	1	04	01	H7028_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7028	002	0	1	04	01	H7028_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7028	002	0	1	04	01	H7028_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7028	002	0	1	04	01	H7028_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	5.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	4.00	6.00				2.00	4.00	5.00				2.00		2.00
H7028	002	0	1	04	01	H7028_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	5.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7028	002	0	1	04	01	H7028_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7028	002	0	1	04	01	H7028_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7028	002	0	1	04	01	H7028_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7063	001	0	1	04	01	H7063_001_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	6.00				0.00	0.00	0.00				3.00		3.00
H7063	001	0	1	04	01	H7063_001_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	001	0	1	04	01	H7063_001_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00				0.00	0.00	0.00				5.00		5.00
H7063	001	0	1	04	01	H7063_001_0	7			Generic	4	01	1	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	001	0	1	04	01	H7063_001_0	7			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H7063	001	0	1	04	01	H7063_001_0	7			Non-Preferred Drug	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H7063	001	0	1	04	01	H7063_001_0	7			Specialty Tier	4	10	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7063	006	0	1	04	01	H7063_006_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	6.00				0.00	0.00	0.00				3.00		3.00
H7063	006	0	1	04	01	H7063_006_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	006	0	1	04	01	H7063_006_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00				0.00	0.00	0.00				5.00		5.00
H7063	006	0	1	04	01	H7063_006_0	7			Generic	4	01	1	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	006	0	1	04	01	H7063_006_0	7			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H7063	006	0	1	04	01	H7063_006_0	7			Non-Preferred Drug	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H7063	006	0	1	04	01	H7063_006_0	7			Specialty Tier	4	10	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7063	007	0	1	04	01	H7063_007_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	6.00				0.00	0.00	0.00				3.00		3.00
H7063	007	0	1	04	01	H7063_007_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	007	0	1	04	01	H7063_007_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00				0.00	0.00	0.00				5.00		5.00
H7063	007	0	1	04	01	H7063_007_0	7			Generic	4	01	1	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	007	0	1	04	01	H7063_007_0	7			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H7063	007	0	1	04	01	H7063_007_0	7			Non-Preferred Drug	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H7063	007	0	1	04	01	H7063_007_0	7			Specialty Tier	4	10	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7063	012	0	1	04	01	H7063_012_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	6.00				0.00	0.00	0.00				3.00		3.00
H7063	012	0	1	04	01	H7063_012_0	6			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			0.00	0.00	0.00																3.00				3.00		0.10			0.00			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	012	0	1	04	01	H7063_012_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	10.00				0.00	0.00	0.00				5.00		5.00
H7063	012	0	1	04	01	H7063_012_0	6			Generic	4	01	1	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	10.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7063	012	0	1	04	01	H7063_012_0	6			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H7063	012	0	1	04	01	H7063_012_0	6			Non-Preferred Drug	4	10	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H7063	012	0	1	04	01	H7063_012_0	6			Specialty Tier	4	10	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7074	001	0	1	04	01	H7074_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7074	001	0	1	04	01	H7074_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7074	001	0	1	04	01	H7074_001_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7074	001	0	1	04	01	H7074_001_0	11			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7074	001	0	1	04	01	H7074_001_0	11			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7074	001	0	1	04	01	H7074_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1180.49	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7074	001	0	1	04	01	H7074_001_0	11			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7074	001	0	1	04	01	H7074_001_0	11			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7093	002	0	1	04	01	H7093_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7093	002	0	1	04	01	H7093_002_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7093	002	0	1	04	01	H7093_002_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7093	002	0	1	04	01	H7093_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H7093	002	0	1	04	01	H7093_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7093	002	0	1	04	01	H7093_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7093	002	0	1	04	01	H7093_002_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7093	002	0	1	04	01	H7093_002_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7115	001	0	1	01	01	H7115_001_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7115	001	0	1	01	01	H7115_001_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7115	001	0	1	01	01	H7115_001_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7115	001	0	1	01	01	H7115_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7115	001	0	1	01	01	H7115_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7115	001	0	1	01	01	H7115_001_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7115	001	0	1	01	01	H7115_001_0	5			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7115	004	0	1	01	01	H7115_004_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7115	004	0	1	01	01	H7115_004_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7115	004	0	1	01	01	H7115_004_0	5			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7115	004	0	1	01	01	H7115_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7115	004	0	1	01	01	H7115_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7115	004	0	1	01	01	H7115_004_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7115	004	0	1	01	01	H7115_004_0	5			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7123	001	0	1	01	01	H7123_001_0	9		N	Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	100	1	2						100	30		31								15.00	30.00	45.00					10.00	17.50	25.00													30.00						25.00				15.00				10.00			0.50	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7123	001	0	1	01	01	H7123_001_0	9		N	Generic	4	11	1	2	2	1		111	01		100	1				30	60	100	1	2						100	30		31								20.00	40.00	60.00					15.00	25.00	35.00													40.00						35.00				20.00				15.00			0.67	0.50				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7123	001	0	1	01	01	H7123_001_0	9		N	Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	100	1	2						100	30		31								47.00	94.00	141.00					40.00	65.00	90.00													95.00						90.00				47.00				40.00			1.57	1.33				1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	65.00	90.00			95.00			87.50	35.00		35.00
H7123	001	0	1	01	01	H7123_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	100	1	2						100	30		31											70.03	49	49	49				75.74	49	49	49												49						49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7123	001	0	1	01	01	H7123_001_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											723.13	25						812.08	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7147	001	0	1	02	01	H7147_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7147	001	0	1	02	01	H7147_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7147	001	0	1	02	01	H7147_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	5.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	4.00	6.00				2.00	4.00	5.00				2		2
H7147	001	0	1	02	01	H7147_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	5.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7147	001	0	1	02	01	H7147_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7147	001	0	1	02	01	H7147_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7147	001	0	1	02	01	H7147_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7147	004	0	1	02	01	H7147_004_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7147	004	0	1	02	01	H7147_004_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7147	004	0	1	02	01	H7147_004_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7147	004	0	1	02	01	H7147_004_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7147	004	0	1	02	01	H7147_004_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7147	004	0	1	02	01	H7147_004_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7147	004	0	1	02	01	H7147_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7147	005	0	1	02	01	H7147_005_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7147	005	0	1	02	01	H7147_005_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7147	005	0	1	02	01	H7147_005_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	9.00	18.00	27.00																			9.00	18.00	22.50																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00				9.00	18.00	22.50				9		9
H7147	005	0	1	02	01	H7147_005_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	9.00	18.00	27.00																			9.00	18.00	22.50																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7147	005	0	1	02	01	H7147_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7147	005	0	1	02	01	H7147_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7147	005	0	1	02	01	H7147_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7149	001	0	1	02	01	H7149_001_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	001	0	1	02	01	H7149_001_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7149	001	0	1	02	01	H7149_001_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	001	0	1	02	01	H7149_001_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7149	001	0	1	02	01	H7149_001_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7149	001	0	1	02	01	H7149_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	001	0	1	02	01	H7149_001_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											733.86	33						622.09	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7149	008	0	1	02	01	H7149_008_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	008	0	1	02	01	H7149_008_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7149	008	0	1	02	01	H7149_008_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	008	0	1	02	01	H7149_008_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7149	008	0	1	02	01	H7149_008_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											98.36	25	25	25				91.23	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7149	008	0	1	02	01	H7149_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.60	50	50	50				45.51	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	008	0	1	02	01	H7149_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											663.75	29						591.90	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7149	009	0	1	02	01	H7149_009_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	009	0	1	02	01	H7149_009_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7149	009	0	1	02	01	H7149_009_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	009	0	1	02	01	H7149_009_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7149	009	0	1	02	01	H7149_009_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.27	25	25	25				75.35	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7149	009	0	1	02	01	H7149_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											34.93	50	50	50				24.92	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7149	009	0	1	02	01	H7149_009_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											924.40	33						639.36	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7151	001	0	1	01	01	H7151_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7151	001	0	1	01	01	H7151_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7151	001	0	1	01	01	H7151_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7151	001	0	1	01	01	H7151_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7151	001	0	1	01	01	H7151_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7151	001	0	1	01	01	H7151_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7151	001	0	1	01	01	H7151_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7151	003	0	1	01	01	H7151_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7151	003	0	1	01	01	H7151_003_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7151	003	0	1	01	01	H7151_003_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	25.00				10		10
H7151	003	0	1	01	01	H7151_003_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7151	003	0	1	01	01	H7151_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7151	003	0	1	01	01	H7151_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7151	003	0	1	01	01	H7151_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7163	002	0	1	02	01	H7163_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	002	0	1	02	01	H7163_002_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7163	002	0	1	02	01	H7163_002_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	002	0	1	02	01	H7163_002_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								16.00	32.00	48.00					12.00	24.00	36.00											16.00	32.00	48.00				12.00	24.00	36.00				16.00				12.00			0.53	0.40		0.53	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7163	002	0	1	02	01	H7163_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7163	002	0	1	02	01	H7163_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7163	002	0	1	02	01	H7163_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											817.47	33						416.10	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	004	0	1	02	01	H7163_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	004	0	1	02	01	H7163_004_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7163	004	0	1	02	01	H7163_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	004	0	1	02	01	H7163_004_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					12.00	24.00	36.00											14.00	28.00	42.00				12.00	24.00	36.00				14.00				12.00			0.47	0.40		0.47	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7163	004	0	1	02	01	H7163_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H7163	004	0	1	02	01	H7163_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H7163	004	0	1	02	01	H7163_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											874.86	33						554.91	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	005	0	1	02	01	H7163_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	005	0	1	02	01	H7163_005_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7163	005	0	1	02	01	H7163_005_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7163	005	0	1	02	01	H7163_005_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								18.00	36.00	54.00					12.00	24.00	36.00											18.00	36.00	54.00				12.00	24.00	36.00				18.00				12.00			0.60	0.40		0.60	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7163	005	0	1	02	01	H7163_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				45.00			1.57	1.50		1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H7163	005	0	1	02	01	H7163_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35		35
H7163	005	0	1	02	01	H7163_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											700.92	29						351.09	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7165	001	0	1	01	01	H7165_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	001	0	1	01	01	H7165_001_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7165	001	0	1	01	01	H7165_001_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	001	0	1	01	01	H7165_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7165	001	0	1	01	01	H7165_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	001	0	1	01	01	H7165_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	001	0	1	01	01	H7165_001_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	001	0	1	01	01	H7165_001_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7165	002	0	1	01	01	H7165_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	002	0	1	01	01	H7165_002_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7165	002	0	1	01	01	H7165_002_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	002	0	1	01	01	H7165_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7165	002	0	1	01	01	H7165_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	002	0	1	01	01	H7165_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	002	0	1	01	01	H7165_002_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7165	002	0	1	01	01	H7165_002_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7169	001	0	1	04	01	H7169_001_0	20			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					0.00	0.00	0.00											7.00	14.00	21.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7169	001	0	1	04	01	H7169_001_0	20			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7169	001	0	1	04	01	H7169_001_0	20			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7169	001	0	1	04	01	H7169_001_0	20			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.65	50	50	50				87.65	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7169	001	0	1	04	01	H7169_001_0	20			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7169	001	0	1	04	01	H7169_001_0	20			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7172	001	0	1	48	05	H7172_001_0	3			Generic Drugs	4	11		2	1	1	111		10	111		1	30	60	90				2	2	30	60	90					29	31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7172	001	0	1	48	05	H7172_001_0	3			Brand Drugs	4	11		2	2	1	111		10	111		1	30	60	90				2	2	30	60	90					29	31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7172	001	0	1	48	05	H7172_001_0	3			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		10	000		1	30	60	90				1	2								29	31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00			0.00	0.00																		
H7175	001	0	1	04	01	H7175_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	001	0	1	04	01	H7175_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	001	0	1	04	01	H7175_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7175	001	0	1	04	01	H7175_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.84	50	50	50				92.84	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7175	001	0	1	04	01	H7175_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7175	001	0	1	04	01	H7175_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	003	0	1	04	01	H7175_003_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	003	0	1	04	01	H7175_003_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	003	0	1	04	01	H7175_003_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H7175	003	0	1	04	01	H7175_003_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.36	46	46	46				98.36	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7175	003	0	1	04	01	H7175_003_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7175	003	0	1	04	01	H7175_003_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	004	0	1	04	01	H7175_004_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	004	0	1	04	01	H7175_004_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	004	0	1	04	01	H7175_004_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7175	004	0	1	04	01	H7175_004_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.08	50	50	50				99.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7175	004	0	1	04	01	H7175_004_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7175	004	0	1	04	01	H7175_004_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7175	004	0	1	04	01	H7175_004_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7199	001	0	1	04	01	H7199_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7199	001	0	1	04	01	H7199_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7199	001	0	1	04	01	H7199_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7199	001	0	1	04	01	H7199_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7199	001	0	1	04	01	H7199_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7199	001	0	1	04	01	H7199_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7199	001	0	1	04	01	H7199_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7199	002	0	1	04	01	H7199_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7199	002	0	1	04	01	H7199_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7199	002	0	1	04	01	H7199_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7199	002	0	1	04	01	H7199_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7199	002	0	1	04	01	H7199_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7199	002	0	1	04	01	H7199_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7199	002	0	1	04	01	H7199_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7220	004	0	1	02	01	H7220_004_0	4			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								6.00	12.00	18.00					3.00	6.00	9.00					6.00	12.00	18.00																6.00				6.00			0.20	0.10	0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	004	0	1	02	01	H7220_004_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								15.00	30.00	45.00					15.00	30.00	45.00					15.00	30.00	45.00																15.00				15.00			0.50	0.50	0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	004	0	1	02	01	H7220_004_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	004	0	1	02	01	H7220_004_0	4			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	004	0	1	02	01	H7220_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	004	0	1	02	01	H7220_004_0	4			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	1	1	01	01	H7220_009_1	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								3.00	6.00	9.00					0.00	0.00	0.00					3.00	6.00	0.00																3.00				3.00			0.10	0.00	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	1	1	01	01	H7220_009_1	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								12.00	24.00	36.00					12.00	24.00	36.00					12.00	24.00	0.00																12.00				12.00			0.40	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	1	1	01	01	H7220_009_1	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	009	1	1	01	01	H7220_009_1	3			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	1	1	01	01	H7220_009_1	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	1	1	01	01	H7220_009_1	3			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	2	1	01	01	H7220_009_2	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								3.00	6.00	9.00					0.00	0.00	0.00					3.00	6.00	0.00																3.00				3.00			0.10	0.00	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	2	1	01	01	H7220_009_2	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								12.00	24.00	36.00					12.00	24.00	36.00					12.00	24.00	0.00																12.00				12.00			0.40	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	2	1	01	01	H7220_009_2	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	009	2	1	01	01	H7220_009_2	3			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	2	1	01	01	H7220_009_2	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	2	1	01	01	H7220_009_2	3			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	3	1	01	01	H7220_009_3	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								3.00	6.00	9.00					0.00	0.00	0.00					3.00	6.00	0.00																3.00				3.00			0.10	0.00	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	3	1	01	01	H7220_009_3	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								12.00	24.00	36.00					12.00	24.00	36.00					12.00	24.00	0.00																12.00				12.00			0.40	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	3	1	01	01	H7220_009_3	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	009	3	1	01	01	H7220_009_3	3			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	3	1	01	01	H7220_009_3	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	009	3	1	01	01	H7220_009_3	3			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	010	0	1	01	01	H7220_010_0	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								3.00	6.00	9.00					0.00	0.00	0.00					3.00	6.00	0.00																3.00				3.00			0.10	0.00	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	010	0	1	01	01	H7220_010_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								12.00	24.00	36.00					12.00	24.00	36.00					12.00	24.00	0.00																12.00				12.00			0.40	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	010	0	1	01	01	H7220_010_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	010	0	1	01	01	H7220_010_0	3			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	010	0	1	01	01	H7220_010_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	010	0	1	01	01	H7220_010_0	3			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	011	0	1	02	01	H7220_011_0	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								3.00	6.00	9.00					0.00	0.00	0.00					3.00	6.00	0.00																3.00				3.00			0.10	0.00	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	011	0	1	02	01	H7220_011_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								12.00	24.00	36.00					12.00	24.00	36.00					12.00	24.00	0.00																12.00				12.00			0.40	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	011	0	1	02	01	H7220_011_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	011	0	1	02	01	H7220_011_0	3			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	011	0	1	02	01	H7220_011_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	011	0	1	02	01	H7220_011_0	3			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	012	0	1	01	01	H7220_012_0	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								3.00	6.00	9.00					0.00	0.00	0.00					3.00	6.00	0.00																3.00				3.00			0.10	0.00	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	012	0	1	01	01	H7220_012_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								12.00	24.00	36.00					12.00	24.00	36.00					12.00	24.00	0.00																12.00				12.00			0.40	0.40	0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	012	0	1	01	01	H7220_012_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																47.00				47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7220	012	0	1	01	01	H7220_012_0	3			Non-Preferred Brand	4	11	1	2	4	1		111	01	111		1				30	60	100	2	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	012	0	1	01	01	H7220_012_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7220	012	0	1	01	01	H7220_012_0	3			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H7245	001	0	1	01	01	H7245_001_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	12.00																			4.00	8.00	0.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													4.00	8.00	12.00				4.00	8.00	0.00				4.00		4.00
H7245	001	0	1	01	01	H7245_001_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	36.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	36.00				12.00	24.00	36.00				12.00		12.00
H7245	001	0	1	01	01	H7245_001_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	42.00	84.00	126.00																			42.00	84.00	126.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7245	001	0	1	01	01	H7245_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7245	001	0	1	01	01	H7245_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7245	001	0	1	01	01	H7245_001_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7245	002	0	1	01	01	H7245_002_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													2.00	4.00	6.00				2.00	4.00	0.00				2.00		2.00
H7245	002	0	1	01	01	H7245_002_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H7245	002	0	1	01	01	H7245_002_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7245	002	0	1	01	01	H7245_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7245	002	0	1	01	01	H7245_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7245	002	0	1	01	01	H7245_002_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7245	005	0	1	01	01	H7245_005_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													2.00	4.00	6.00				2.00	4.00	0.00				2.00		2.00
H7245	005	0	1	01	01	H7245_005_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	30.00				10.00	20.00	30.00				10.00		10.00
H7245	005	0	1	01	01	H7245_005_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7245	005	0	1	01	01	H7245_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7245	005	0	1	01	01	H7245_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7245	005	0	1	01	01	H7245_005_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7273	001	0	1	04	01	H7273_001_0	10			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H7273	001	0	1	04	01	H7273_001_0	10			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7273	001	0	1	04	01	H7273_001_0	10			Generic	4	01	1	2	2	1	110		01	100		1	31		90				1	2			90				31		31	5.00		15.00																					10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00						10.00				5.00		5.00
H7273	001	0	1	04	01	H7273_001_0	10			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H7273	001	0	1	04	01	H7273_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					300.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H7273	001	0	1	04	01	H7273_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				933.33	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7273	002	0	1	04	01	H7273_002_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H7273	002	0	1	04	01	H7273_002_0	9			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7273	002	0	1	04	01	H7273_002_0	9			Generic	4	01	1	2	2	1	110		01	100		1	31		90				1	2			90				31		31	5.00		15.00																					10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00						10.00				5.00		5.00
H7273	002	0	1	04	01	H7273_002_0	9			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H7273	002	0	1	04	01	H7273_002_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					300.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H7273	002	0	1	04	01	H7273_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				938.10	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7273	005	0	1	04	01	H7273_005_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00						0.00				0.00		0.00
H7273	005	0	1	04	01	H7273_005_0	9			Preferred Generic	4	01	1	2	1	3	110		01	100		1	31		90				1	2			90				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7273	005	0	1	04	01	H7273_005_0	9			Generic	4	01	1	2	2	1	110		01	100		1	31		90				1	2			90				31		31	5.00		15.00																					10.00																5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00						10.00				5.00		5.00
H7273	005	0	1	04	01	H7273_005_0	9			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	47.00		141.00																					141.00																47.00				47.00		1.52						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H7273	005	0	1	04	01	H7273_005_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					300.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
H7273	005	0	1	04	01	H7273_005_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		31				905.80	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7284	001	0	1	04	01	H7284_001_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				10.00		30.00	2.00		0.00	2.00		2.00
H7284	001	0	1	04	01	H7284_001_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									10.00		30.00				2.00		0.00				2.00				2.00		0.07				0.33	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7284	001	0	1	04	01	H7284_001_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H7284	001	0	1	04	01	H7284_001_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7284	001	0	1	04	01	H7284_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	001	0	1	04	01	H7284_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	001	0	1	04	01	H7284_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7284	006	0	1	04	01	H7284_006_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H7284	006	0	1	04	01	H7284_006_0	5			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7284	006	0	1	04	01	H7284_006_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H7284	006	0	1	04	01	H7284_006_0	5			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7284	006	0	1	04	01	H7284_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	006	0	1	04	01	H7284_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	006	0	1	04	01	H7284_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7284	007	0	1	04	01	H7284_007_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H7284	007	0	1	04	01	H7284_007_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H7284	007	0	1	04	01	H7284_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	30.00		90.00																									47.00		141.00				30.00		80.00				30.00				30.00		1.00				1.57	1.00	0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													30.00		90.00				35.00		105.00	30.00		80.00	30.00		30.00
H7284	007	0	1	04	01	H7284_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	007	0	1	04	01	H7284_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7284	008	0	1	04	01	H7284_008_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H7284	008	0	1	04	01	H7284_008_0	5			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H7284	008	0	1	04	01	H7284_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	008	0	1	04	01	H7284_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	008	0	1	04	01	H7284_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7284	009	0	1	04	01	H7284_009_0	11			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H7284	009	0	1	04	01	H7284_009_0	11			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7284	009	0	1	04	01	H7284_009_0	11			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H7284	009	0	1	04	01	H7284_009_0	11			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7284	009	0	1	04	01	H7284_009_0	11			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	009	0	1	04	01	H7284_009_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7284	009	0	1	04	01	H7284_009_0	11			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7301	002	0	1	04	01	H7301_002_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	002	0	1	04	01	H7301_002_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7301	002	0	1	04	01	H7301_002_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	002	0	1	04	01	H7301_002_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7301	002	0	1	04	01	H7301_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	002	0	1	04	01	H7301_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	002	0	1	04	01	H7301_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											976.11	33						599.71	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	006	0	1	04	01	H7301_006_0	7			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	006	0	1	04	01	H7301_006_0	7			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7301	006	0	1	04	01	H7301_006_0	7			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	006	0	1	04	01	H7301_006_0	7			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7301	006	0	1	04	01	H7301_006_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	006	0	1	04	01	H7301_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	006	0	1	04	01	H7301_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											914.73	33						651.25	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	007	0	1	04	01	H7301_007_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	007	0	1	04	01	H7301_007_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	007	0	1	04	01	H7301_007_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	007	0	1	04	01	H7301_007_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	007	0	1	04	01	H7301_007_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	007	0	1	04	01	H7301_007_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	007	0	1	04	01	H7301_007_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											757.16	33						769.46	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	009	0	1	04	01	H7301_009_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	009	0	1	04	01	H7301_009_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	009	0	1	04	01	H7301_009_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	009	0	1	04	01	H7301_009_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	009	0	1	04	01	H7301_009_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	009	0	1	04	01	H7301_009_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	009	0	1	04	01	H7301_009_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											667.64	33						659.18	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	013	0	1	04	01	H7301_013_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	013	0	1	04	01	H7301_013_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	013	0	1	04	01	H7301_013_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	013	0	1	04	01	H7301_013_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	013	0	1	04	01	H7301_013_0	8			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											88.82	25	25	25				77.46	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	013	0	1	04	01	H7301_013_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.08	50	50	50				26.54	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	013	0	1	04	01	H7301_013_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											894.60	33						660.59	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	014	0	1	04	01	H7301_014_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	014	0	1	04	01	H7301_014_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	014	0	1	04	01	H7301_014_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	014	0	1	04	01	H7301_014_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	014	0	1	04	01	H7301_014_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											105.69	25	25	25				97.08	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	014	0	1	04	01	H7301_014_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.45	40	40	40				42.85	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	014	0	1	04	01	H7301_014_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											648.43	27						588.85	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	015	0	1	04	01	H7301_015_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	015	0	1	04	01	H7301_015_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	015	0	1	04	01	H7301_015_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.96	25	25	25				118.99	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	015	0	1	04	01	H7301_015_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.11	40	40	40				41.97	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	015	0	1	04	01	H7301_015_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											842.67	28						569.80	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	016	0	1	04	01	H7301_016_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	016	0	1	04	01	H7301_016_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	016	0	1	04	01	H7301_016_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											106.35	25	25	25				119.87	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	016	0	1	04	01	H7301_016_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.04	40	40	40				42.71	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	016	0	1	04	01	H7301_016_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											737.12	28						497.42	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	017	0	1	04	01	H7301_017_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	017	0	1	04	01	H7301_017_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	017	0	1	04	01	H7301_017_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	017	0	1	04	01	H7301_017_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	017	0	1	04	01	H7301_017_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.67	25	25	25				82.28	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	017	0	1	04	01	H7301_017_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.20	50	50	50				33.19	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	017	0	1	04	01	H7301_017_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											770.84	33						691.77	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7301	021	0	1	04	01	H7301_021_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	021	0	1	04	01	H7301_021_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	021	0	1	04	01	H7301_021_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	021	0	1	04	01	H7301_021_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7301	021	0	1	04	01	H7301_021_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											104.54	25	25	25				94.70	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7301	021	0	1	04	01	H7301_021_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.77	50	50	50				50.85	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7301	021	0	1	04	01	H7301_021_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											803.49	29						595.68	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7323	002	0	1	04	01	H7323_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	002	0	1	04	01	H7323_002_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	002	0	1	04	01	H7323_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	002	0	1	04	01	H7323_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	002	0	1	04	01	H7323_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.47	46	46	46				98.47	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	002	0	1	04	01	H7323_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	002	0	1	04	01	H7323_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	002	0	1	04	01	H7323_002_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7323	003	0	1	04	01	H7323_003_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	003	0	1	04	01	H7323_003_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	003	0	1	04	01	H7323_003_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	003	0	1	04	01	H7323_003_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	003	0	1	04	01	H7323_003_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.82	50	50	50				99.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	003	0	1	04	01	H7323_003_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	003	0	1	04	01	H7323_003_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	003	0	1	04	01	H7323_003_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7323	006	0	1	04	01	H7323_006_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	006	0	1	04	01	H7323_006_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	006	0	1	04	01	H7323_006_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	006	0	1	04	01	H7323_006_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.63	50	50	50				89.63	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	006	0	1	04	01	H7323_006_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	006	0	1	04	01	H7323_006_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	007	0	1	04	01	H7323_007_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	007	0	1	04	01	H7323_007_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	007	0	1	04	01	H7323_007_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	0.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	007	0	1	04	01	H7323_007_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	007	0	1	04	01	H7323_007_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.96	47	47	47				97.96	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	007	0	1	04	01	H7323_007_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	007	0	1	04	01	H7323_007_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	007	0	1	04	01	H7323_007_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7323	009	0	1	04	01	H7323_009_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	009	0	1	04	01	H7323_009_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	009	0	1	04	01	H7323_009_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	009	0	1	04	01	H7323_009_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	009	0	1	04	01	H7323_009_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.37	43	43	43				98.37	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	009	0	1	04	01	H7323_009_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	009	0	1	04	01	H7323_009_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	009	0	1	04	01	H7323_009_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7323	010	0	1	04	01	H7323_010_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	010	0	1	04	01	H7323_010_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	010	0	1	04	01	H7323_010_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	010	0	1	04	01	H7323_010_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	010	0	1	04	01	H7323_010_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											94.22	50	50	50				94.22	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	010	0	1	04	01	H7323_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	010	0	1	04	01	H7323_010_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	010	0	1	04	01	H7323_010_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7323	011	0	1	04	01	H7323_011_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	011	0	1	04	01	H7323_011_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	011	0	1	04	01	H7323_011_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	011	0	1	04	01	H7323_011_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	011	0	1	04	01	H7323_011_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.20	48	48	48				98.20	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	011	0	1	04	01	H7323_011_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	011	0	1	04	01	H7323_011_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	011	0	1	04	01	H7323_011_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7323	012	0	1	04	01	H7323_012_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	012	0	1	04	01	H7323_012_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7323	012	0	1	04	01	H7323_012_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	012	0	1	04	01	H7323_012_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7323	012	0	1	04	01	H7323_012_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.20	48	48	48				98.20	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7323	012	0	1	04	01	H7323_012_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7323	012	0	1	04	01	H7323_012_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7323	012	0	1	04	01	H7323_012_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7326	001	0	1	04	01	H7326_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	001	0	1	04	01	H7326_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	001	0	1	04	01	H7326_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7326	001	0	1	04	01	H7326_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											85.05	50	50	50				85.05	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7326	001	0	1	04	01	H7326_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7326	001	0	1	04	01	H7326_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	001	0	1	04	01	H7326_001_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7326	003	0	1	04	01	H7326_003_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	003	0	1	04	01	H7326_003_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	003	0	1	04	01	H7326_003_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7326	003	0	1	04	01	H7326_003_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.74	50	50	50				91.74	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7326	003	0	1	04	01	H7326_003_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7326	003	0	1	04	01	H7326_003_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	003	0	1	04	01	H7326_003_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7326	007	0	1	04	01	H7326_007_0	7			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	007	0	1	04	01	H7326_007_0	7			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7326	007	0	1	04	01	H7326_007_0	7			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H7326	007	0	1	04	01	H7326_007_0	7			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.56	46	46	46				98.56	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7326	007	0	1	04	01	H7326_007_0	7			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7326	007	0	1	04	01	H7326_007_0	7			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	001	0	1	01	01	H7330_001_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7330	001	0	1	01	01	H7330_001_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7330	001	0	1	01	01	H7330_001_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	001	0	1	01	01	H7330_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	001	0	1	01	01	H7330_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	001	0	1	01	01	H7330_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	003	0	1	01	01	H7330_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7330	003	0	1	01	01	H7330_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7330	003	0	1	01	01	H7330_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	003	0	1	01	01	H7330_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	003	0	1	01	01	H7330_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	003	0	1	01	01	H7330_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	003	0	1	01	01	H7330_003_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	004	0	1	01	01	H7330_004_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7330	004	0	1	01	01	H7330_004_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7330	004	0	1	01	01	H7330_004_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	004	0	1	01	01	H7330_004_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	004	0	1	01	01	H7330_004_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	004	0	1	01	01	H7330_004_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7330	007	0	1	01	01	H7330_007_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7330	007	0	1	01	01	H7330_007_0	9			Generic	4	11	3	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		0	0	0															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	007	0	1	01	01	H7330_007_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	007	0	1	01	01	H7330_007_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	007	0	1	01	01	H7330_007_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7330	007	0	1	01	01	H7330_007_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7360	001	0	1	04	01	H7360_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7360	001	0	1	04	01	H7360_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	0.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7360	001	0	1	04	01	H7360_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7360	001	0	1	04	01	H7360_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											75.22	50	50	50				75.22	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7360	001	0	1	04	01	H7360_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H7360	001	0	1	04	01	H7360_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7389	001	0	1	01	01	H7389_001_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7389	001	0	1	01	01	H7389_001_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7389	001	0	1	01	01	H7389_001_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7389	001	0	1	01	01	H7389_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	001	0	1	01	01	H7389_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	001	0	1	01	01	H7389_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											588.60	33						506.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7389	002	0	1	01	01	H7389_002_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7389	002	0	1	01	01	H7389_002_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7389	002	0	1	01	01	H7389_002_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7389	002	0	1	01	01	H7389_002_0	8			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7389	002	0	1	01	01	H7389_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	002	0	1	01	01	H7389_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	002	0	1	01	01	H7389_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											543.63	33						450.98	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7389	003	0	1	01	01	H7389_003_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7389	003	0	1	01	01	H7389_003_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7389	003	0	1	01	01	H7389_003_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7389	003	0	1	01	01	H7389_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	003	0	1	01	01	H7389_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	003	0	1	01	01	H7389_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											612.57	33						556.50	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7389	004	0	1	01	01	H7389_004_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7389	004	0	1	01	01	H7389_004_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7389	004	0	1	01	01	H7389_004_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7389	004	0	1	01	01	H7389_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	004	0	1	01	01	H7389_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	004	0	1	01	01	H7389_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											621.95	33						490.80	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7389	008	0	1	01	01	H7389_008_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7389	008	0	1	01	01	H7389_008_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7389	008	0	1	01	01	H7389_008_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7389	008	0	1	01	01	H7389_008_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7389	008	0	1	01	01	H7389_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	008	0	1	01	01	H7389_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	008	0	1	01	01	H7389_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											633.67	33						478.25	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7389	011	0	1	01	01	H7389_011_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7389	011	0	1	01	01	H7389_011_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7389	011	0	1	01	01	H7389_011_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7389	011	0	1	01	01	H7389_011_0	8			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7389	011	0	1	01	01	H7389_011_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	011	0	1	01	01	H7389_011_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7389	011	0	1	01	01	H7389_011_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											691.31	33						525.82	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7399	001	0	1	01	01	H7399_001_0	9			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7399	001	0	1	01	01	H7399_001_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	0.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7399	001	0	1	01	01	H7399_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7399	001	0	1	01	01	H7399_001_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											95.58	50	50	50				95.58	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7399	001	0	1	01	01	H7399_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7399	001	0	1	01	01	H7399_001_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7404	001	0	1	04	01	H7404_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	001	0	1	04	01	H7404_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	001	0	1	04	01	H7404_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	001	0	1	04	01	H7404_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	001	0	1	04	01	H7404_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	001	0	1	04	01	H7404_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	001	0	1	04	01	H7404_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				469.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	002	0	1	04	01	H7404_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	002	0	1	04	01	H7404_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	002	0	1	04	01	H7404_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	002	0	1	04	01	H7404_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	002	0	1	04	01	H7404_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	002	0	1	04	01	H7404_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	002	0	1	04	01	H7404_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				587.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	005	0	1	04	01	H7404_005_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	005	0	1	04	01	H7404_005_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	005	0	1	04	01	H7404_005_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	005	0	1	04	01	H7404_005_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	005	0	1	04	01	H7404_005_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	005	0	1	04	01	H7404_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	005	0	1	04	01	H7404_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				482.00	26																										26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	006	0	1	04	01	H7404_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	006	0	1	04	01	H7404_006_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	006	0	1	04	01	H7404_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	006	0	1	04	01	H7404_006_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	006	0	1	04	01	H7404_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	006	0	1	04	01	H7404_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	006	0	1	04	01	H7404_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				304.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	011	0	1	04	01	H7404_011_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	011	0	1	04	01	H7404_011_0	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	011	0	1	04	01	H7404_011_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	011	0	1	04	01	H7404_011_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	011	0	1	04	01	H7404_011_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	011	0	1	04	01	H7404_011_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	011	0	1	04	01	H7404_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				343.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	012	0	1	04	01	H7404_012_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	012	0	1	04	01	H7404_012_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	012	0	1	04	01	H7404_012_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	012	0	1	04	01	H7404_012_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	012	0	1	04	01	H7404_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	012	0	1	04	01	H7404_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	012	0	1	04	01	H7404_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				343.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	014	0	1	04	01	H7404_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	014	0	1	04	01	H7404_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	014	0	1	04	01	H7404_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	014	0	1	04	01	H7404_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	014	0	1	04	01	H7404_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	014	0	1	04	01	H7404_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	014	0	1	04	01	H7404_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				369.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	018	0	1	04	01	H7404_018_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	018	0	1	04	01	H7404_018_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	018	0	1	04	01	H7404_018_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	018	0	1	04	01	H7404_018_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	018	0	1	04	01	H7404_018_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	018	0	1	04	01	H7404_018_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	018	0	1	04	01	H7404_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				482.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	020	0	1	04	01	H7404_020_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	020	0	1	04	01	H7404_020_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	020	0	1	04	01	H7404_020_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	020	0	1	04	01	H7404_020_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		15.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	020	0	1	04	01	H7404_020_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	020	0	1	04	01	H7404_020_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	020	0	1	04	01	H7404_020_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				369.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	021	0	1	04	01	H7404_021_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	021	0	1	04	01	H7404_021_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	021	0	1	04	01	H7404_021_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	021	0	1	04	01	H7404_021_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	021	0	1	04	01	H7404_021_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	021	0	1	04	01	H7404_021_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	021	0	1	04	01	H7404_021_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				609.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	022	0	1	04	01	H7404_022_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	022	0	1	04	01	H7404_022_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	022	0	1	04	01	H7404_022_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	022	0	1	04	01	H7404_022_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	022	0	1	04	01	H7404_022_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	022	0	1	04	01	H7404_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	022	0	1	04	01	H7404_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	023	0	1	04	01	H7404_023_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	023	0	1	04	01	H7404_023_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	023	0	1	04	01	H7404_023_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	023	0	1	04	01	H7404_023_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	023	0	1	04	01	H7404_023_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	023	0	1	04	01	H7404_023_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	023	0	1	04	01	H7404_023_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				244.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	024	0	1	04	01	H7404_024_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	024	0	1	04	01	H7404_024_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	024	0	1	04	01	H7404_024_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	024	0	1	04	01	H7404_024_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	024	0	1	04	01	H7404_024_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	024	0	1	04	01	H7404_024_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	024	0	1	04	01	H7404_024_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				330.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	025	0	1	04	01	H7404_025_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	025	0	1	04	01	H7404_025_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7404	025	0	1	04	01	H7404_025_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7404	025	0	1	04	01	H7404_025_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7404	025	0	1	04	01	H7404_025_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	025	0	1	04	01	H7404_025_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H7404	025	0	1	04	01	H7404_025_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				494.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7419	001	0	1	48	05	H7419_001_0	2			$0 Drugs	4	11		2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	$0 Drugs, Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7419	001	0	1	48	05	H7419_001_0	2			Generic Drugs	4	01		2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	$0 Drugs, Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7419	001	0	1	48	05	H7419_001_0	2			Brand Drugs	4	10		2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	$0 Drugs, Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7419	001	0	1	48	05	H7419_001_0	2			Non-Medicare Rx/OTC Drugs	4	11		2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	$0 Drugs, Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7511	002	0	1	01	01	H7511_002_0	8			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	4.00	8.00	12.00																																						4.00			4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7511	002	0	1	01	01	H7511_002_0	8			Generic	4	01	1	2	2	1	111		10			1	30	60	90				2	2								10	31	10.00	20.00	30.00																																						10.00			10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7511	002	0	1	01	01	H7511_002_0	8			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				2	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00										35.00		35.00
H7511	002	0	1	01	01	H7511_002_0	8			Non-Preferred Drug	4	10	1	2	4	1	111		10			1	30	60	90				2	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00										35.00		35.00
H7511	002	0	1	01	01	H7511_002_0	8			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31					33	33	33																																				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7511	002	0	1	01	01	H7511_002_0	8			Select Care Drugs	4	11	1	2	6	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7518	001	0	1	04	01	H7518_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7518	001	0	1	04	01	H7518_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7518	001	0	1	04	01	H7518_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7518	001	0	1	04	01	H7518_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											75.88	50	50	50				75.88	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7518	001	0	1	04	01	H7518_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7518	001	0	1	04	01	H7518_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7518	004	0	1	04	01	H7518_004_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7518	004	0	1	04	01	H7518_004_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7518	004	0	1	04	01	H7518_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7518	004	0	1	04	01	H7518_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.87	50	50	50				87.87	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7518	004	0	1	04	01	H7518_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H7518	004	0	1	04	01	H7518_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7524	001	0	1	01	01	H7524_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7524	001	0	1	01	01	H7524_001_0	6		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H7524	001	0	1	01	01	H7524_001_0	6		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	001	0	1	01	01	H7524_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				98.00	27	27	27																		27	27	27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	001	0	1	01	01	H7524_001_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	002	0	1	01	01	H7524_002_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7524	002	0	1	01	01	H7524_002_0	7		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H7524	002	0	1	01	01	H7524_002_0	7		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	002	0	1	01	01	H7524_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				97.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	002	0	1	01	01	H7524_002_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	003	0	1	01	01	H7524_003_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7524	003	0	1	01	01	H7524_003_0	6		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H7524	003	0	1	01	01	H7524_003_0	6		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	003	0	1	01	01	H7524_003_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				99.00	27	27	27																		27	27	27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	003	0	1	01	01	H7524_003_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	004	0	1	01	01	H7524_004_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7524	004	0	1	01	01	H7524_004_0	7		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00
H7524	004	0	1	01	01	H7524_004_0	7		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	004	0	1	01	01	H7524_004_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				98.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7524	004	0	1	01	01	H7524_004_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7559	003	0	1	01	01	H7559_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7559	003	0	1	01	01	H7559_003_0	11			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7559	003	0	1	01	01	H7559_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H7559	003	0	1	01	01	H7559_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7559	003	0	1	01	01	H7559_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1145.41	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7559	003	0	1	01	01	H7559_003_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7605	001	0	1	01	01	H7605_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	001	0	1	01	01	H7605_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	001	0	1	01	01	H7605_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	001	0	1	01	01	H7605_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7605	001	0	1	01	01	H7605_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	001	0	1	01	01	H7605_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	001	0	1	01	01	H7605_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7605	002	0	1	01	01	H7605_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	002	0	1	01	01	H7605_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	002	0	1	01	01	H7605_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00				7.00	14.00	17.50				7		7
H7605	002	0	1	01	01	H7605_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7605	002	0	1	01	01	H7605_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	002	0	1	01	01	H7605_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	002	0	1	01	01	H7605_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7605	003	0	1	01	01	H7605_003_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	003	0	1	01	01	H7605_003_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	003	0	1	01	01	H7605_003_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	003	0	1	01	01	H7605_003_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7605	003	0	1	01	01	H7605_003_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	003	0	1	01	01	H7605_003_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	003	0	1	01	01	H7605_003_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7605	004	0	1	01	01	H7605_004_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	004	0	1	01	01	H7605_004_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	004	0	1	01	01	H7605_004_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	004	0	1	01	01	H7605_004_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7605	004	0	1	01	01	H7605_004_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	004	0	1	01	01	H7605_004_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	97.00	194.00	291.00																			97.00	194.00	291.00																97.00				97.00		3.23			3.23			3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H7605	004	0	1	01	01	H7605_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H7605	005	0	1	01	01	H7605_005_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	005	0	1	01	01	H7605_005_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	005	0	1	01	01	H7605_005_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00				7.00	14.00	17.50				7.00		7.00
H7605	005	0	1	01	01	H7605_005_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7605	005	0	1	01	01	H7605_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	005	0	1	01	01	H7605_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	005	0	1	01	01	H7605_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7605	007	0	1	01	01	H7605_007_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	007	0	1	01	01	H7605_007_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	007	0	1	01	01	H7605_007_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	007	0	1	01	01	H7605_007_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7605	007	0	1	01	01	H7605_007_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	007	0	1	01	01	H7605_007_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	007	0	1	01	01	H7605_007_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7605	008	0	1	01	01	H7605_008_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	008	0	1	01	01	H7605_008_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	008	0	1	01	01	H7605_008_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00				7.00	14.00	17.50				7.00		7.00
H7605	008	0	1	01	01	H7605_008_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7605	008	0	1	01	01	H7605_008_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	008	0	1	01	01	H7605_008_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	008	0	1	01	01	H7605_008_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7605	009	0	1	01	01	H7605_009_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	009	0	1	01	01	H7605_009_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	009	0	1	01	01	H7605_009_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	009	0	1	01	01	H7605_009_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7605	009	0	1	01	01	H7605_009_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	009	0	1	01	01	H7605_009_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	009	0	1	01	01	H7605_009_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7605	010	0	1	01	01	H7605_010_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	010	0	1	01	01	H7605_010_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7605	010	0	1	01	01	H7605_010_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7605	010	0	1	01	01	H7605_010_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7605	010	0	1	01	01	H7605_010_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	010	0	1	01	01	H7605_010_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7605	010	0	1	01	01	H7605_010_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7607	002	1	1	01	01	H7607_002_1	15			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	1	1	01	01	H7607_002_1	15			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	1	1	01	01	H7607_002_1	15			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	002	1	1	01	01	H7607_002_1	15			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	1	1	01	01	H7607_002_1	15			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	002	1	1	01	01	H7607_002_1	15			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.16						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	002	1	1	01	01	H7607_002_1	15			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	1	1	01	01	H7607_002_1	15			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				812.64	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	1	1	01	01	H7607_002_1	15			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	2	1	01	01	H7607_002_2	15			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	2	1	01	01	H7607_002_2	15			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	2	1	01	01	H7607_002_2	15			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	002	2	1	01	01	H7607_002_2	15			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	2	1	01	01	H7607_002_2	15			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	002	2	1	01	01	H7607_002_2	15			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.16						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	002	2	1	01	01	H7607_002_2	15			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	2	1	01	01	H7607_002_2	15			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				812.64	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	2	1	01	01	H7607_002_2	15			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	3	1	01	01	H7607_002_3	15			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	3	1	01	01	H7607_002_3	15			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	3	1	01	01	H7607_002_3	15			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	002	3	1	01	01	H7607_002_3	15			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	3	1	01	01	H7607_002_3	15			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	002	3	1	01	01	H7607_002_3	15			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.16						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	002	3	1	01	01	H7607_002_3	15			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	3	1	01	01	H7607_002_3	15			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				812.64	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	3	1	01	01	H7607_002_3	15			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	4	1	01	01	H7607_002_4	15			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	4	1	01	01	H7607_002_4	15			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	4	1	01	01	H7607_002_4	15			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	002	4	1	01	01	H7607_002_4	15			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	4	1	01	01	H7607_002_4	15			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	002	4	1	01	01	H7607_002_4	15			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.16						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	002	4	1	01	01	H7607_002_4	15			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	4	1	01	01	H7607_002_4	15			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				812.64	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	4	1	01	01	H7607_002_4	15			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	5	1	01	01	H7607_002_5	15			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	5	1	01	01	H7607_002_5	15			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	5	1	01	01	H7607_002_5	15			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	002	5	1	01	01	H7607_002_5	15			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	002	5	1	01	01	H7607_002_5	15			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	002	5	1	01	01	H7607_002_5	15			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	35.00		105.00																					70.00																35.00				35.00		1.16						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	002	5	1	01	01	H7607_002_5	15			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	5	1	01	01	H7607_002_5	15			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				812.64	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	002	5	1	01	01	H7607_002_5	15			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	1	1	01	01	H7607_007_1	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	1	1	01	01	H7607_007_1	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	1	1	01	01	H7607_007_1	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	007	1	1	01	01	H7607_007_1	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	1	1	01	01	H7607_007_1	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	007	1	1	01	01	H7607_007_1	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	007	1	1	01	01	H7607_007_1	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	1	1	01	01	H7607_007_1	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				1302.61	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	1	1	01	01	H7607_007_1	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	2	1	01	01	H7607_007_2	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	2	1	01	01	H7607_007_2	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	2	1	01	01	H7607_007_2	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	007	2	1	01	01	H7607_007_2	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	2	1	01	01	H7607_007_2	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	007	2	1	01	01	H7607_007_2	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	007	2	1	01	01	H7607_007_2	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	2	1	01	01	H7607_007_2	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				1302.61	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	2	1	01	01	H7607_007_2	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	3	1	01	01	H7607_007_3	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	3	1	01	01	H7607_007_3	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	3	1	01	01	H7607_007_3	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	007	3	1	01	01	H7607_007_3	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	3	1	01	01	H7607_007_3	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	007	3	1	01	01	H7607_007_3	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	007	3	1	01	01	H7607_007_3	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	3	1	01	01	H7607_007_3	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				1302.61	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	3	1	01	01	H7607_007_3	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	4	1	01	01	H7607_007_4	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	4	1	01	01	H7607_007_4	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	4	1	01	01	H7607_007_4	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	007	4	1	01	01	H7607_007_4	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	4	1	01	01	H7607_007_4	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	007	4	1	01	01	H7607_007_4	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	007	4	1	01	01	H7607_007_4	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	4	1	01	01	H7607_007_4	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				1302.61	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	4	1	01	01	H7607_007_4	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	5	1	01	01	H7607_007_5	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	5	1	01	01	H7607_007_5	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	5	1	01	01	H7607_007_5	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													0.00		0.00						0.00				0.00		0.00
H7607	007	5	1	01	01	H7607_007_5	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	007	5	1	01	01	H7607_007_5	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	007	5	1	01	01	H7607_007_5	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	007	5	1	01	01	H7607_007_5	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	5	1	01	01	H7607_007_5	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				1302.61	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	007	5	1	01	01	H7607_007_5	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	1	1	01	01	H7607_008_1	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	1	1	01	01	H7607_008_1	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	1	1	01	01	H7607_008_1	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													10.00		30.00						20.00				10.00		10.00
H7607	008	1	1	01	01	H7607_008_1	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	1	1	01	01	H7607_008_1	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	008	1	1	01	01	H7607_008_1	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	008	1	1	01	01	H7607_008_1	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	1	1	01	01	H7607_008_1	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				914.16	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	1	1	01	01	H7607_008_1	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	2	1	01	01	H7607_008_2	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	2	1	01	01	H7607_008_2	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	2	1	01	01	H7607_008_2	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													10.00		30.00						20.00				10.00		10.00
H7607	008	2	1	01	01	H7607_008_2	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	2	1	01	01	H7607_008_2	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	008	2	1	01	01	H7607_008_2	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	008	2	1	01	01	H7607_008_2	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	2	1	01	01	H7607_008_2	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				914.16	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	2	1	01	01	H7607_008_2	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	3	1	01	01	H7607_008_3	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	3	1	01	01	H7607_008_3	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	3	1	01	01	H7607_008_3	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													10.00		30.00						20.00				10.00		10.00
H7607	008	3	1	01	01	H7607_008_3	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	3	1	01	01	H7607_008_3	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	008	3	1	01	01	H7607_008_3	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	008	3	1	01	01	H7607_008_3	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	3	1	01	01	H7607_008_3	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				914.16	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	3	1	01	01	H7607_008_3	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	4	1	01	01	H7607_008_4	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	4	1	01	01	H7607_008_4	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	4	1	01	01	H7607_008_4	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													10.00		30.00						20.00				10.00		10.00
H7607	008	4	1	01	01	H7607_008_4	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	4	1	01	01	H7607_008_4	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	008	4	1	01	01	H7607_008_4	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	008	4	1	01	01	H7607_008_4	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	4	1	01	01	H7607_008_4	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				914.16	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	4	1	01	01	H7607_008_4	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	5	1	01	01	H7607_008_5	16			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	5	1	01	01	H7607_008_5	16			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	5	1	01	01	H7607_008_5	16			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	10.00		30.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													10.00		30.00						20.00				10.00		10.00
H7607	008	5	1	01	01	H7607_008_5	16			Generic	4	01	1	2	2	3	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										1																	
H7607	008	5	1	01	01	H7607_008_5	16			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	008	5	1	01	01	H7607_008_5	16			Preferred Brand	4	10	1	2	3	3	110		01	100		1	30		100				2	2			100				30		31	47.00		141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs										2																	
H7607	008	5	1	01	01	H7607_008_5	16			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				2	2			100				30		31	99.00		297.00																					198.00																99.00				99.00		3.30						3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	5	1	01	01	H7607_008_5	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				914.16	33		33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	008	5	1	01	01	H7607_008_5	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	1	1	01	01	H7607_011_1	16			Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				0.25	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	1	1	01	01	H7607_011_1	16			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				15.86	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	1	1	01	01	H7607_011_1	16			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				136.09	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	1	1	01	01	H7607_011_1	16			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				2	2			100				30		31				80.26	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	1	1	01	01	H7607_011_1	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				630.04	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	1	1	01	01	H7607_011_1	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	2	1	01	01	H7607_011_2	16			Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				0.25	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	2	1	01	01	H7607_011_2	16			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				15.86	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	2	1	01	01	H7607_011_2	16			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				136.09	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	2	1	01	01	H7607_011_2	16			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				2	2			100				30		31				80.26	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	2	1	01	01	H7607_011_2	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				630.04	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	2	1	01	01	H7607_011_2	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	4	1	01	01	H7607_011_4	16			Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				0.25	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	4	1	01	01	H7607_011_4	16			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				15.86	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	4	1	01	01	H7607_011_4	16			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				136.09	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	4	1	01	01	H7607_011_4	16			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				2	2			100				30		31				80.26	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	4	1	01	01	H7607_011_4	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				630.04	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	4	1	01	01	H7607_011_4	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	5	1	01	01	H7607_011_5	16			Preferred Generic	4	01	1	1	1	1	110		01	100		1	30		100				2	2			100				30		31				0.25	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	5	1	01	01	H7607_011_5	16			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				15.86	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	5	1	01	01	H7607_011_5	16			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				136.09	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs													35.00		105.00						70.00				35.00		35.00
H7607	011	5	1	01	01	H7607_011_5	16			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				2	2			100				30		31				80.26	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	5	1	01	01	H7607_011_5	16			Specialty Tier	4	11	1	1	5	1	110		01	100		1	30		100				2	2			100				30		31				630.04	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7607	011	5	1	01	01	H7607_011_5	16			Supplemental Drugs	4	01	2	2	6	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Supplemental Drugs																											
H7621	002	0	1	01	01	H7621_002_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H7621	002	0	1	01	01	H7621_002_0	4			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7621	002	0	1	01	01	H7621_002_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H7621	002	0	1	01	01	H7621_002_0	4			Generic	4	11	3	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7621	002	0	1	01	01	H7621_002_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7621	002	0	1	01	01	H7621_002_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7621	002	0	1	01	01	H7621_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7621	003	0	1	01	01	H7621_003_0	4			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H7621	003	0	1	01	01	H7621_003_0	4			Generic	4	11	3	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
H7621	003	0	1	01	01	H7621_003_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7621	003	0	1	01	01	H7621_003_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H7621	003	0	1	01	01	H7621_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H7646	001	0	1	02	01	H7646_001_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H7646	001	0	1	02	01	H7646_001_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H7646	001	0	1	02	01	H7646_001_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					45.00	90.00	112.50																45.00				45.00			1.50	1.33	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	001	0	1	02	01	H7646_001_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								95.00	190.00	285.00					90.00	180.00	270.00					95.00	190.00	237.50																95.00				95.00			3.17	3.00	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	001	0	1	02	01	H7646_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7646	002	0	1	02	01	H7646_002_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H7646	002	0	1	02	01	H7646_002_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H7646	002	0	1	02	01	H7646_002_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					45.00	90.00	112.50																45.00				45.00			1.50	1.33	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	002	0	1	02	01	H7646_002_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								95.00	190.00	285.00					90.00	180.00	270.00					95.00	190.00	237.50																95.00				95.00			3.17	3.00	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	002	0	1	02	01	H7646_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7646	004	0	1	02	01	H7646_004_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H7646	004	0	1	02	01	H7646_004_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H7646	004	0	1	02	01	H7646_004_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					45.00	90.00	112.50																45.00				45.00			1.50	1.33	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	004	0	1	02	01	H7646_004_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								95.00	190.00	285.00					90.00	180.00	270.00					95.00	190.00	237.50																95.00				95.00			3.17	3.00	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	004	0	1	02	01	H7646_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7646	005	0	1	02	01	H7646_005_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H7646	005	0	1	02	01	H7646_005_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H7646	005	0	1	02	01	H7646_005_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					45.00	90.00	112.50																45.00				45.00			1.50	1.33	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	005	0	1	02	01	H7646_005_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								95.00	190.00	285.00					90.00	180.00	270.00					95.00	190.00	237.50																95.00				95.00			3.17	3.00	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	005	0	1	02	01	H7646_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7646	007	0	1	02	01	H7646_007_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H7646	007	0	1	02	01	H7646_007_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H7646	007	0	1	02	01	H7646_007_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					45.00	90.00	112.50																45.00				45.00			1.50	1.33	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	007	0	1	02	01	H7646_007_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								95.00	190.00	285.00					90.00	180.00	270.00					95.00	190.00	237.50																95.00				95.00			3.17	3.00	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	007	0	1	02	01	H7646_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7646	008	0	1	02	01	H7646_008_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00
H7646	008	0	1	02	01	H7646_008_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H7646	008	0	1	02	01	H7646_008_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					45.00	90.00	112.50																45.00				45.00			1.50	1.33	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	008	0	1	02	01	H7646_008_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								95.00	190.00	285.00					90.00	180.00	270.00					95.00	190.00	237.50																95.00				95.00			3.17	3.00	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H7646	008	0	1	02	01	H7646_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	001	0	1	01	01	H7670_001_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	001	0	1	01	01	H7670_001_0	7			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7670	001	0	1	01	01	H7670_001_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	001	0	1	01	01	H7670_001_0	7			Generic	4	11	3	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7670	001	0	1	01	01	H7670_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H7670	001	0	1	01	01	H7670_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	001	0	1	01	01	H7670_001_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31				562.21	30	30	30																		30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	002	0	1	01	01	H7670_002_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	002	0	1	01	01	H7670_002_0	6			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7670	002	0	1	01	01	H7670_002_0	6			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	002	0	1	01	01	H7670_002_0	6			Generic	4	11	3	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7670	002	0	1	01	01	H7670_002_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H7670	002	0	1	01	01	H7670_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7670	002	0	1	01	01	H7670_002_0	6			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	1	30	60	90				30		31				617.55	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7678	004	0	1	01	01	H7678_004_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	004	0	1	01	01	H7678_004_0	6			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	004	0	1	01	01	H7678_004_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H7678	004	0	1	01	01	H7678_004_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	004	0	1	01	01	H7678_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				666.41	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7678	004	0	1	01	01	H7678_004_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	005	0	1	01	01	H7678_005_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	005	0	1	01	01	H7678_005_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	20.00	40.00	60.00																			20.00	40.00	40.00																20.00				20.00		0.65			0.65			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	005	0	1	01	01	H7678_005_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H7678	005	0	1	01	01	H7678_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7678	005	0	1	01	01	H7678_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				754.32	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7678	005	0	1	01	01	H7678_005_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	001	0	1	01	01	H7680_001_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	001	0	1	01	01	H7680_001_0	7			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7680	001	0	1	01	01	H7680_001_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H7680	001	0	1	01	01	H7680_001_0	7			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	001	0	1	01	01	H7680_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H7680	001	0	1	01	01	H7680_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	001	0	1	01	01	H7680_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				155.72	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	001	0	1	01	01	H7680_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	001	0	1	01	01	H7680_001_0	7			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	002	0	1	01	01	H7680_002_0	8			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	002	0	1	01	01	H7680_002_0	8			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7680	002	0	1	01	01	H7680_002_0	8			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H7680	002	0	1	01	01	H7680_002_0	8			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	002	0	1	01	01	H7680_002_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H7680	002	0	1	01	01	H7680_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	002	0	1	01	01	H7680_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				123.56	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	002	0	1	01	01	H7680_002_0	8			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	002	0	1	01	01	H7680_002_0	8			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	007	0	1	01	01	H7680_007_0	7		N	Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				0.97	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	007	0	1	01	01	H7680_007_0	7		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				5.70	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H7680	007	0	1	01	01	H7680_007_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				148.56	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H7680	007	0	1	01	01	H7680_007_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				51.22	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	007	0	1	01	01	H7680_007_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				194.86	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	007	0	1	01	01	H7680_007_0	7		N	Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				0.74	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	009	0	1	01	01	H7680_009_0	7			Preferred Generic	4	01	3	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				1.17	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	009	0	1	01	01	H7680_009_0	7			Generic	4	01	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				5.37	17	17	17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H7680	009	0	1	01	01	H7680_009_0	7			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				141.10	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						105.00				35.00		35.00
H7680	009	0	1	01	01	H7680_009_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				40.76	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	009	0	1	01	01	H7680_009_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				188.53	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	009	0	1	01	01	H7680_009_0	7			Select Care Drugs	4	01	1	1	6	1	111		01	100		1	30	60	100				1	2			100				30		31				1.00	15	15	15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	011	0	1	01	01	H7680_011_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	011	0	1	01	01	H7680_011_0	6			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7680	011	0	1	01	01	H7680_011_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H7680	011	0	1	01	01	H7680_011_0	6			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	011	0	1	01	01	H7680_011_0	6			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	42.00	84.00	84.00																					84.00																42.00				42.00		1.40						1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H7680	011	0	1	01	01	H7680_011_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	011	0	1	01	01	H7680_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				123.72	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	011	0	1	01	01	H7680_011_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	011	0	1	01	01	H7680_011_0	6			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	012	0	1	01	01	H7680_012_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	012	0	1	01	01	H7680_012_0	6			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7680	012	0	1	01	01	H7680_012_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H7680	012	0	1	01	01	H7680_012_0	6			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	012	0	1	01	01	H7680_012_0	6			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	35.00	70.00	70.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H7680	012	0	1	01	01	H7680_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	012	0	1	01	01	H7680_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				248.27	28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	012	0	1	01	01	H7680_012_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	012	0	1	01	01	H7680_012_0	6			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	014	0	1	01	01	H7680_014_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	014	0	1	01	01	H7680_014_0	7			Preferred Generic	4	01	3	2	1	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7680	014	0	1	01	01	H7680_014_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													12.00	24.00	24.00						24.00				12.00		12.00
H7680	014	0	1	01	01	H7680_014_0	7			Generic	4	01	1	2	2	3	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7680	014	0	1	01	01	H7680_014_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	42.00	84.00	84.00																					84.00																42.00				42.00		1.40						1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	70.00						70.00				35.00		35.00
H7680	014	0	1	01	01	H7680_014_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	014	0	1	01	01	H7680_014_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				123.72	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	014	0	1	01	01	H7680_014_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7680	014	0	1	01	01	H7680_014_0	7			Select Care Drugs	4	01	1	2	6	3	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7746	001	0	1	01	01	H7746_001_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H7746	001	0	1	01	01	H7746_001_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H7746	001	0	1	01	01	H7746_001_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H7746	001	0	1	01	01	H7746_001_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H7746	001	0	1	01	01	H7746_001_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H7746	001	0	1	01	01	H7746_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7746	001	0	1	01	01	H7746_001_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H7746	001	0	1	01	01	H7746_001_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H7746	002	0	1	01	01	H7746_002_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H7746	002	0	1	01	01	H7746_002_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H7746	002	0	1	01	01	H7746_002_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H7746	002	0	1	01	01	H7746_002_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H7746	002	0	1	01	01	H7746_002_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H7746	002	0	1	01	01	H7746_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7746	002	0	1	01	01	H7746_002_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H7746	002	0	1	01	01	H7746_002_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H7746	003	0	1	02	01	H7746_003_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H7746	003	0	1	02	01	H7746_003_0	6			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H7746	003	0	1	02	01	H7746_003_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				2	2			90				30		31	12.00	24.00	36.00																					27.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													10.00	20.00	30.00						23.00				10.00		10.00
H7746	003	0	1	02	01	H7746_003_0	6			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	47.00	94.00	141.00																					105.75																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H7746	003	0	1	02	01	H7746_003_0	6			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				2	2			90				30		31	100.00	200.00	300.00																					225.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00						79.00				35.00		35.00
H7746	003	0	1	02	01	H7746_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1500.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H7746	003	0	1	02	01	H7746_003_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													0.00	0.00	0.00						0.00				0.00		0.00
H7746	003	0	1	02	01	H7746_003_0	6			Select Care Drugs	4	11	1	2	6	3	111		01	100		1	30	60	90				2	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs										1																	
H7787	001	0	1	04	01	H7787_001_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7787	001	0	1	04	01	H7787_001_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7787	001	0	1	04	01	H7787_001_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7787	001	0	1	04	01	H7787_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7787	001	0	1	04	01	H7787_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7787	001	0	1	04	01	H7787_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											792.47	33						536.19	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7833	001	0	1	48	05	H7833_001_0	4			Generic Drugs	4	01			1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																																					Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	4.50	0.00	4.50	0.00	4.50	0.00	4.50																		
H7833	001	0	1	48	05	H7833_001_0	4			Brand Drugs	4	10			2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																																					Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	11.20	0.00	11.20	0.00	11.20	0.00	11.20																		
H7833	001	0	1	48	05	H7833_001_0	4			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7844	001	0	1	48	05	H7844_001_0	7			Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7844	001	0	1	48	05	H7844_001_0	7			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7844	001	0	1	48	05	H7844_001_0	7			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31								31						31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H7849	001	0	1	04	01	H7849_001_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	001	0	1	04	01	H7849_001_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	001	0	1	04	01	H7849_001_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	001	0	1	04	01	H7849_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	001	0	1	04	01	H7849_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	001	0	1	04	01	H7849_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											729.73	33						473.41	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	002	0	1	04	01	H7849_002_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	002	0	1	04	01	H7849_002_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	002	0	1	04	01	H7849_002_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	002	0	1	04	01	H7849_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	002	0	1	04	01	H7849_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	002	0	1	04	01	H7849_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											593.28	33						689.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	003	0	1	04	01	H7849_003_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	003	0	1	04	01	H7849_003_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	003	0	1	04	01	H7849_003_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	003	0	1	04	01	H7849_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	003	0	1	04	01	H7849_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	003	0	1	04	01	H7849_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											661.12	33						614.85	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	006	0	1	04	01	H7849_006_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	006	0	1	04	01	H7849_006_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	006	0	1	04	01	H7849_006_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	006	0	1	04	01	H7849_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	006	0	1	04	01	H7849_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	006	0	1	04	01	H7849_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											720.56	33						605.71	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	013	0	1	04	01	H7849_013_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	013	0	1	04	01	H7849_013_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	013	0	1	04	01	H7849_013_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	013	0	1	04	01	H7849_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	013	0	1	04	01	H7849_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	013	0	1	04	01	H7849_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											744.26	33						389.75	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	014	0	1	04	01	H7849_014_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	014	0	1	04	01	H7849_014_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	014	0	1	04	01	H7849_014_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	014	0	1	04	01	H7849_014_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7849	014	0	1	04	01	H7849_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	014	0	1	04	01	H7849_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	014	0	1	04	01	H7849_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											561.86	33						519.70	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	015	0	1	04	01	H7849_015_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	015	0	1	04	01	H7849_015_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	015	0	1	04	01	H7849_015_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	015	0	1	04	01	H7849_015_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	015	0	1	04	01	H7849_015_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	015	0	1	04	01	H7849_015_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											717.50	33						460.72	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	017	0	1	04	01	H7849_017_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	017	0	1	04	01	H7849_017_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	017	0	1	04	01	H7849_017_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	017	0	1	04	01	H7849_017_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	017	0	1	04	01	H7849_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	017	0	1	04	01	H7849_017_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											814.88	33						571.77	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	018	0	1	04	01	H7849_018_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	018	0	1	04	01	H7849_018_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	018	0	1	04	01	H7849_018_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	018	0	1	04	01	H7849_018_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	018	0	1	04	01	H7849_018_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	018	0	1	04	01	H7849_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											777.47	33						487.98	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	020	0	1	04	01	H7849_020_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	020	0	1	04	01	H7849_020_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	020	0	1	04	01	H7849_020_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H7849	020	0	1	04	01	H7849_020_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	020	0	1	04	01	H7849_020_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	020	0	1	04	01	H7849_020_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											567.83	33						538.19	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	021	0	1	04	01	H7849_021_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	021	0	1	04	01	H7849_021_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	021	0	1	04	01	H7849_021_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H7849	021	0	1	04	01	H7849_021_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	021	0	1	04	01	H7849_021_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	021	0	1	04	01	H7849_021_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											584.01	33						514.53	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	022	0	1	04	01	H7849_022_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	022	0	1	04	01	H7849_022_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	022	0	1	04	01	H7849_022_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H7849	022	0	1	04	01	H7849_022_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	022	0	1	04	01	H7849_022_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	022	0	1	04	01	H7849_022_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											760.15	33						451.23	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	023	0	1	04	01	H7849_023_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	023	0	1	04	01	H7849_023_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	023	0	1	04	01	H7849_023_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	10.00	20.00	30.00	15.00	30.00	45.00	10.00	20.00	0.00	15.00		15.00
H7849	023	0	1	04	01	H7849_023_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	023	0	1	04	01	H7849_023_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	023	0	1	04	01	H7849_023_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											700.96	33						503.81	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	024	0	1	04	01	H7849_024_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	024	0	1	04	01	H7849_024_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	024	0	1	04	01	H7849_024_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	024	0	1	04	01	H7849_024_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	024	0	1	04	01	H7849_024_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	024	0	1	04	01	H7849_024_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											804.44	33						315.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	026	0	1	04	01	H7849_026_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	026	0	1	04	01	H7849_026_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	026	0	1	04	01	H7849_026_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	026	0	1	04	01	H7849_026_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	026	0	1	04	01	H7849_026_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	026	0	1	04	01	H7849_026_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.53	33						512.84	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	027	0	1	04	01	H7849_027_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	027	0	1	04	01	H7849_027_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	027	0	1	04	01	H7849_027_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	027	0	1	04	01	H7849_027_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	027	0	1	04	01	H7849_027_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	027	0	1	04	01	H7849_027_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											738.07	33						448.99	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	029	0	1	04	01	H7849_029_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	029	0	1	04	01	H7849_029_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	029	0	1	04	01	H7849_029_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	029	0	1	04	01	H7849_029_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	029	0	1	04	01	H7849_029_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	029	0	1	04	01	H7849_029_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											545.30	33						439.37	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	030	0	1	04	01	H7849_030_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	030	0	1	04	01	H7849_030_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	030	0	1	04	01	H7849_030_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	030	0	1	04	01	H7849_030_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	030	0	1	04	01	H7849_030_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	030	0	1	04	01	H7849_030_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											594.78	33						468.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	031	0	1	04	01	H7849_031_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	031	0	1	04	01	H7849_031_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	031	0	1	04	01	H7849_031_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	031	0	1	04	01	H7849_031_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	031	0	1	04	01	H7849_031_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	031	0	1	04	01	H7849_031_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											575.21	33						406.40	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	033	0	1	04	01	H7849_033_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	033	0	1	04	01	H7849_033_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	033	0	1	04	01	H7849_033_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	033	0	1	04	01	H7849_033_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	033	0	1	04	01	H7849_033_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	033	0	1	04	01	H7849_033_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											585.20	33						440.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	034	0	1	04	01	H7849_034_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	034	0	1	04	01	H7849_034_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	034	0	1	04	01	H7849_034_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	034	0	1	04	01	H7849_034_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	034	0	1	04	01	H7849_034_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	034	0	1	04	01	H7849_034_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											681.65	33						458.27	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	037	0	1	04	01	H7849_037_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	037	0	1	04	01	H7849_037_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	037	0	1	04	01	H7849_037_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	037	0	1	04	01	H7849_037_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	037	0	1	04	01	H7849_037_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	037	0	1	04	01	H7849_037_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											580.34	33						542.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	038	0	1	04	01	H7849_038_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	038	0	1	04	01	H7849_038_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	038	0	1	04	01	H7849_038_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	038	0	1	04	01	H7849_038_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	038	0	1	04	01	H7849_038_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	038	0	1	04	01	H7849_038_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											641.29	33						481.90	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	039	0	1	04	01	H7849_039_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	039	0	1	04	01	H7849_039_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	039	0	1	04	01	H7849_039_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	039	0	1	04	01	H7849_039_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	039	0	1	04	01	H7849_039_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	039	0	1	04	01	H7849_039_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											705.26	33						547.91	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	041	0	1	04	01	H7849_041_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	041	0	1	04	01	H7849_041_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	041	0	1	04	01	H7849_041_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	041	0	1	04	01	H7849_041_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	041	0	1	04	01	H7849_041_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	041	0	1	04	01	H7849_041_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											586.91	33						562.90	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	042	0	1	04	01	H7849_042_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	042	0	1	04	01	H7849_042_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	042	0	1	04	01	H7849_042_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	042	0	1	04	01	H7849_042_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	042	0	1	04	01	H7849_042_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	042	0	1	04	01	H7849_042_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											431.13	33						759.37	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	044	0	1	04	01	H7849_044_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	044	0	1	04	01	H7849_044_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	044	0	1	04	01	H7849_044_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	044	0	1	04	01	H7849_044_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	044	0	1	04	01	H7849_044_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	044	0	1	04	01	H7849_044_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											556.37	33						700.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	045	0	1	04	01	H7849_045_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	045	0	1	04	01	H7849_045_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	045	0	1	04	01	H7849_045_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	045	0	1	04	01	H7849_045_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	045	0	1	04	01	H7849_045_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	045	0	1	04	01	H7849_045_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											857.06	33						550.71	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	047	0	1	04	01	H7849_047_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	047	0	1	04	01	H7849_047_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	047	0	1	04	01	H7849_047_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	047	0	1	04	01	H7849_047_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	047	0	1	04	01	H7849_047_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	047	0	1	04	01	H7849_047_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.20	33						512.23	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	048	0	1	04	01	H7849_048_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	048	0	1	04	01	H7849_048_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	048	0	1	04	01	H7849_048_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H7849	048	0	1	04	01	H7849_048_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	048	0	1	04	01	H7849_048_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	048	0	1	04	01	H7849_048_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											691.70	33						500.40	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	050	0	1	04	01	H7849_050_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	050	0	1	04	01	H7849_050_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	050	0	1	04	01	H7849_050_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	050	0	1	04	01	H7849_050_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	050	0	1	04	01	H7849_050_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	050	0	1	04	01	H7849_050_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											662.43	33						517.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	051	0	1	04	01	H7849_051_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	051	0	1	04	01	H7849_051_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	051	0	1	04	01	H7849_051_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	051	0	1	04	01	H7849_051_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	051	0	1	04	01	H7849_051_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	051	0	1	04	01	H7849_051_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											665.17	33						547.27	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	052	0	1	04	01	H7849_052_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	052	0	1	04	01	H7849_052_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	052	0	1	04	01	H7849_052_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	052	0	1	04	01	H7849_052_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	052	0	1	04	01	H7849_052_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	052	0	1	04	01	H7849_052_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											561.09	33						473.01	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	054	0	1	04	01	H7849_054_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	054	0	1	04	01	H7849_054_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	054	0	1	04	01	H7849_054_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	054	0	1	04	01	H7849_054_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	054	0	1	04	01	H7849_054_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	054	0	1	04	01	H7849_054_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											724.50	33						540.20	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	055	0	1	04	01	H7849_055_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	055	0	1	04	01	H7849_055_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	055	0	1	04	01	H7849_055_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	055	0	1	04	01	H7849_055_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7849	055	0	1	04	01	H7849_055_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	055	0	1	04	01	H7849_055_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	055	0	1	04	01	H7849_055_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											719.17	33						508.89	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	056	0	1	04	01	H7849_056_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	056	0	1	04	01	H7849_056_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	056	0	1	04	01	H7849_056_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	056	0	1	04	01	H7849_056_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7849	056	0	1	04	01	H7849_056_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	056	0	1	04	01	H7849_056_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	056	0	1	04	01	H7849_056_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											580.97	33						453.46	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	057	0	1	04	01	H7849_057_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	057	0	1	04	01	H7849_057_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	057	0	1	04	01	H7849_057_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	057	0	1	04	01	H7849_057_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	057	0	1	04	01	H7849_057_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	057	0	1	04	01	H7849_057_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											466.60	33						501.69	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	058	0	1	04	01	H7849_058_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	058	0	1	04	01	H7849_058_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	058	0	1	04	01	H7849_058_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	058	0	1	04	01	H7849_058_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	058	0	1	04	01	H7849_058_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	058	0	1	04	01	H7849_058_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											545.78	33						464.64	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	059	0	1	04	01	H7849_059_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	059	0	1	04	01	H7849_059_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	059	0	1	04	01	H7849_059_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	059	0	1	04	01	H7849_059_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	059	0	1	04	01	H7849_059_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	059	0	1	04	01	H7849_059_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											456.09	33						462.26	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	060	0	1	04	01	H7849_060_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	060	0	1	04	01	H7849_060_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	060	0	1	04	01	H7849_060_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	060	0	1	04	01	H7849_060_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	060	0	1	04	01	H7849_060_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	060	0	1	04	01	H7849_060_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											696.23	33						488.87	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	064	1	1	04	01	H7849_064_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	064	1	1	04	01	H7849_064_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	064	1	1	04	01	H7849_064_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	064	1	1	04	01	H7849_064_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	1	1	04	01	H7849_064_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	1	1	04	01	H7849_064_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.25	33						411.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	064	2	1	04	01	H7849_064_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	064	2	1	04	01	H7849_064_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	064	2	1	04	01	H7849_064_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	064	2	1	04	01	H7849_064_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	2	1	04	01	H7849_064_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	2	1	04	01	H7849_064_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.25	33						411.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	064	3	1	04	01	H7849_064_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	064	3	1	04	01	H7849_064_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	064	3	1	04	01	H7849_064_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	064	3	1	04	01	H7849_064_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	3	1	04	01	H7849_064_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	3	1	04	01	H7849_064_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.25	33						411.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	064	4	1	04	01	H7849_064_4	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	064	4	1	04	01	H7849_064_4	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	064	4	1	04	01	H7849_064_4	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	064	4	1	04	01	H7849_064_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	4	1	04	01	H7849_064_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	064	4	1	04	01	H7849_064_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											749.25	33						411.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	065	0	1	04	01	H7849_065_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	065	0	1	04	01	H7849_065_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	065	0	1	04	01	H7849_065_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	10.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	065	0	1	04	01	H7849_065_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7849	065	0	1	04	01	H7849_065_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	065	0	1	04	01	H7849_065_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	065	0	1	04	01	H7849_065_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											636.41	33						479.07	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	066	0	1	04	01	H7849_066_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	066	0	1	04	01	H7849_066_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	066	0	1	04	01	H7849_066_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	10.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	066	0	1	04	01	H7849_066_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	10.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7849	066	0	1	04	01	H7849_066_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	066	0	1	04	01	H7849_066_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	066	0	1	04	01	H7849_066_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											636.91	33						479.07	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	067	0	1	04	01	H7849_067_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	067	0	1	04	01	H7849_067_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	067	0	1	04	01	H7849_067_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	067	0	1	04	01	H7849_067_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	067	0	1	04	01	H7849_067_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	195.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	067	0	1	04	01	H7849_067_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											614.20	33						439.31	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	068	0	1	04	01	H7849_068_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	068	0	1	04	01	H7849_068_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	068	0	1	04	01	H7849_068_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	068	0	1	04	01	H7849_068_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	068	0	1	04	01	H7849_068_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	068	0	1	04	01	H7849_068_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											614.64	33						440.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	070	0	1	04	01	H7849_070_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	070	0	1	04	01	H7849_070_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	070	0	1	04	01	H7849_070_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	070	0	1	04	01	H7849_070_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	070	0	1	04	01	H7849_070_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	070	0	1	04	01	H7849_070_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											633.29	33						531.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	071	0	1	04	01	H7849_071_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	071	0	1	04	01	H7849_071_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	071	0	1	04	01	H7849_071_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	071	0	1	04	01	H7849_071_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	071	0	1	04	01	H7849_071_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	071	0	1	04	01	H7849_071_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											630.98	33						529.24	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	076	0	1	04	01	H7849_076_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	076	0	1	04	01	H7849_076_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	076	0	1	04	01	H7849_076_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	076	0	1	04	01	H7849_076_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	076	0	1	04	01	H7849_076_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	076	0	1	04	01	H7849_076_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											606.31	33						493.60	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	077	0	1	04	01	H7849_077_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	077	0	1	04	01	H7849_077_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	077	0	1	04	01	H7849_077_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	077	0	1	04	01	H7849_077_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	077	0	1	04	01	H7849_077_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	077	0	1	04	01	H7849_077_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											606.26	33						493.41	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	080	0	1	04	01	H7849_080_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	080	0	1	04	01	H7849_080_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	080	0	1	04	01	H7849_080_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	080	0	1	04	01	H7849_080_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	080	0	1	04	01	H7849_080_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	080	0	1	04	01	H7849_080_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.59	33						657.54	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	081	0	1	04	01	H7849_081_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	081	0	1	04	01	H7849_081_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	081	0	1	04	01	H7849_081_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	081	0	1	04	01	H7849_081_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	081	0	1	04	01	H7849_081_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	081	0	1	04	01	H7849_081_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											622.22	33						531.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	082	0	1	04	01	H7849_082_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	082	0	1	04	01	H7849_082_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	082	0	1	04	01	H7849_082_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	082	0	1	04	01	H7849_082_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	082	0	1	04	01	H7849_082_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	082	0	1	04	01	H7849_082_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.32	33						534.21	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	083	0	1	04	01	H7849_083_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	083	0	1	04	01	H7849_083_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	083	0	1	04	01	H7849_083_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	083	0	1	04	01	H7849_083_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	083	0	1	04	01	H7849_083_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	083	0	1	04	01	H7849_083_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.25	33						534.23	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	084	0	1	04	01	H7849_084_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	084	0	1	04	01	H7849_084_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	084	0	1	04	01	H7849_084_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	084	0	1	04	01	H7849_084_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	084	0	1	04	01	H7849_084_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	084	0	1	04	01	H7849_084_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.38	33						534.24	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	085	0	1	04	01	H7849_085_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	085	0	1	04	01	H7849_085_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	085	0	1	04	01	H7849_085_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	085	0	1	04	01	H7849_085_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	085	0	1	04	01	H7849_085_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	085	0	1	04	01	H7849_085_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.31	33						534.34	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	087	0	1	04	01	H7849_087_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	087	0	1	04	01	H7849_087_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	087	0	1	04	01	H7849_087_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	087	0	1	04	01	H7849_087_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	087	0	1	04	01	H7849_087_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	087	0	1	04	01	H7849_087_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.33	33						534.16	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	088	0	1	04	01	H7849_088_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	088	0	1	04	01	H7849_088_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	088	0	1	04	01	H7849_088_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	088	0	1	04	01	H7849_088_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	088	0	1	04	01	H7849_088_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	088	0	1	04	01	H7849_088_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											746.09	33						514.07	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	101	0	1	04	01	H7849_101_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	101	0	1	04	01	H7849_101_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	101	0	1	04	01	H7849_101_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	101	0	1	04	01	H7849_101_0	7			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7849	101	0	1	04	01	H7849_101_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	101	0	1	04	01	H7849_101_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	101	0	1	04	01	H7849_101_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.10	33						501.91	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	102	1	1	04	01	H7849_102_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	102	1	1	04	01	H7849_102_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	102	1	1	04	01	H7849_102_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	102	1	1	04	01	H7849_102_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	1	1	04	01	H7849_102_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	1	1	04	01	H7849_102_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											729.78	33						522.18	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	102	2	1	04	01	H7849_102_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	102	2	1	04	01	H7849_102_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	102	2	1	04	01	H7849_102_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	102	2	1	04	01	H7849_102_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	2	1	04	01	H7849_102_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	2	1	04	01	H7849_102_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											729.78	33						522.18	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	102	3	1	04	01	H7849_102_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	102	3	1	04	01	H7849_102_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	102	3	1	04	01	H7849_102_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	102	3	1	04	01	H7849_102_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	3	1	04	01	H7849_102_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	3	1	04	01	H7849_102_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											729.78	33						522.18	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	102	4	1	04	01	H7849_102_4	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	102	4	1	04	01	H7849_102_4	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	102	4	1	04	01	H7849_102_4	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	102	4	1	04	01	H7849_102_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	4	1	04	01	H7849_102_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	102	4	1	04	01	H7849_102_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											729.78	33						522.18	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	103	0	1	04	01	H7849_103_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	103	0	1	04	01	H7849_103_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	103	0	1	04	01	H7849_103_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	103	0	1	04	01	H7849_103_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	103	0	1	04	01	H7849_103_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	103	0	1	04	01	H7849_103_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											609.97	33						593.45	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	104	0	1	04	01	H7849_104_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	104	0	1	04	01	H7849_104_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	104	0	1	04	01	H7849_104_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	104	0	1	04	01	H7849_104_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	104	0	1	04	01	H7849_104_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	104	0	1	04	01	H7849_104_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											706.70	33						534.92	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	105	0	1	04	01	H7849_105_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	105	0	1	04	01	H7849_105_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	105	0	1	04	01	H7849_105_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	105	0	1	04	01	H7849_105_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	105	0	1	04	01	H7849_105_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	105	0	1	04	01	H7849_105_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											700.00	33						563.60	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	106	0	1	04	01	H7849_106_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	106	0	1	04	01	H7849_106_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	106	0	1	04	01	H7849_106_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	106	0	1	04	01	H7849_106_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	106	0	1	04	01	H7849_106_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	106	0	1	04	01	H7849_106_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.57	33						533.90	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	107	0	1	04	01	H7849_107_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	107	0	1	04	01	H7849_107_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	107	0	1	04	01	H7849_107_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	107	0	1	04	01	H7849_107_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	107	0	1	04	01	H7849_107_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	107	0	1	04	01	H7849_107_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											707.57	33						535.29	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	108	0	1	04	01	H7849_108_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	108	0	1	04	01	H7849_108_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	108	0	1	04	01	H7849_108_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	108	0	1	04	01	H7849_108_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	108	0	1	04	01	H7849_108_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	108	0	1	04	01	H7849_108_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											705.61	33						533.73	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	109	0	1	04	01	H7849_109_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	109	0	1	04	01	H7849_109_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	109	0	1	04	01	H7849_109_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	109	0	1	04	01	H7849_109_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	109	0	1	04	01	H7849_109_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	109	0	1	04	01	H7849_109_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											709.69	33						535.73	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	110	0	1	04	01	H7849_110_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	110	0	1	04	01	H7849_110_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	110	0	1	04	01	H7849_110_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	110	0	1	04	01	H7849_110_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	110	0	1	04	01	H7849_110_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	110	0	1	04	01	H7849_110_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											707.19	33						534.17	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	111	0	1	04	01	H7849_111_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	111	0	1	04	01	H7849_111_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	111	0	1	04	01	H7849_111_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	111	0	1	04	01	H7849_111_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	111	0	1	04	01	H7849_111_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	111	0	1	04	01	H7849_111_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.40	33						533.76	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	112	1	1	04	01	H7849_112_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	112	1	1	04	01	H7849_112_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	112	1	1	04	01	H7849_112_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	112	1	1	04	01	H7849_112_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	112	1	1	04	01	H7849_112_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	112	1	1	04	01	H7849_112_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											577.77	33						410.91	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	112	2	1	04	01	H7849_112_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	112	2	1	04	01	H7849_112_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	112	2	1	04	01	H7849_112_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	112	2	1	04	01	H7849_112_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	112	2	1	04	01	H7849_112_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	112	2	1	04	01	H7849_112_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											577.77	33						410.91	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	113	1	1	04	01	H7849_113_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	113	1	1	04	01	H7849_113_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	113	1	1	04	01	H7849_113_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H7849	113	1	1	04	01	H7849_113_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	1	1	04	01	H7849_113_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	1	1	04	01	H7849_113_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.77	33						447.56	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	113	2	1	04	01	H7849_113_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	113	2	1	04	01	H7849_113_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	113	2	1	04	01	H7849_113_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H7849	113	2	1	04	01	H7849_113_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	2	1	04	01	H7849_113_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	2	1	04	01	H7849_113_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.77	33						447.56	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	113	3	1	04	01	H7849_113_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	113	3	1	04	01	H7849_113_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	113	3	1	04	01	H7849_113_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H7849	113	3	1	04	01	H7849_113_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	3	1	04	01	H7849_113_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	3	1	04	01	H7849_113_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.77	33						447.56	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	113	4	1	04	01	H7849_113_4	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	113	4	1	04	01	H7849_113_4	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	113	4	1	04	01	H7849_113_4	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		20.00
H7849	113	4	1	04	01	H7849_113_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	4	1	04	01	H7849_113_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	113	4	1	04	01	H7849_113_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.77	33						447.56	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	114	0	1	04	01	H7849_114_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	114	0	1	04	01	H7849_114_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	114	0	1	04	01	H7849_114_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	114	0	1	04	01	H7849_114_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					35.00	70.00	105.00											47.00	94.00	141.00				35.00	70.00	105.00				47.00				47.00			1.57	1.17		1.57	1.17	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	114	0	1	04	01	H7849_114_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	114	0	1	04	01	H7849_114_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											627.69	33						539.46	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	115	0	1	04	01	H7849_115_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	115	0	1	04	01	H7849_115_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	115	0	1	04	01	H7849_115_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	115	0	1	04	01	H7849_115_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	115	0	1	04	01	H7849_115_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	115	0	1	04	01	H7849_115_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											750.55	33						550.44	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	116	0	1	04	01	H7849_116_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	116	0	1	04	01	H7849_116_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	116	0	1	04	01	H7849_116_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H7849	116	0	1	04	01	H7849_116_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					40.00	80.00	120.00											47.00	94.00	141.00				40.00	80.00	120.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	116	0	1	04	01	H7849_116_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	116	0	1	04	01	H7849_116_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.37	33						565.15	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	117	1	1	04	01	H7849_117_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	117	1	1	04	01	H7849_117_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	117	1	1	04	01	H7849_117_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	117	1	1	04	01	H7849_117_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	117	1	1	04	01	H7849_117_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	117	1	1	04	01	H7849_117_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											630.44	33						438.53	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	117	2	1	04	01	H7849_117_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	117	2	1	04	01	H7849_117_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	117	2	1	04	01	H7849_117_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	117	2	1	04	01	H7849_117_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	117	2	1	04	01	H7849_117_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	117	2	1	04	01	H7849_117_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											630.44	33						438.53	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	118	0	1	04	01	H7849_118_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	118	0	1	04	01	H7849_118_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	118	0	1	04	01	H7849_118_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	118	0	1	04	01	H7849_118_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	118	0	1	04	01	H7849_118_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	118	0	1	04	01	H7849_118_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											631.86	33						437.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	119	0	1	04	01	H7849_119_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	119	0	1	04	01	H7849_119_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	119	0	1	04	01	H7849_119_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	119	0	1	04	01	H7849_119_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	119	0	1	04	01	H7849_119_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	119	0	1	04	01	H7849_119_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											631.86	33						437.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	120	0	1	04	01	H7849_120_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	120	0	1	04	01	H7849_120_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	120	0	1	04	01	H7849_120_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	120	0	1	04	01	H7849_120_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	120	0	1	04	01	H7849_120_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	120	0	1	04	01	H7849_120_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											631.86	33						437.35	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	121	0	1	04	01	H7849_121_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	121	0	1	04	01	H7849_121_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H7849	121	0	1	04	01	H7849_121_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H7849	121	0	1	04	01	H7849_121_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	121	0	1	04	01	H7849_121_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	121	0	1	04	01	H7849_121_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											629.01	33						438.47	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	123	0	1	04	01	H7849_123_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	123	0	1	04	01	H7849_123_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	123	0	1	04	01	H7849_123_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	123	0	1	04	01	H7849_123_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	123	0	1	04	01	H7849_123_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	123	0	1	04	01	H7849_123_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											774.88	33						512.05	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	124	1	1	04	01	H7849_124_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	124	1	1	04	01	H7849_124_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	124	1	1	04	01	H7849_124_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	124	1	1	04	01	H7849_124_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	124	1	1	04	01	H7849_124_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	124	1	1	04	01	H7849_124_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.99	33						585.02	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	124	2	1	04	01	H7849_124_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	124	2	1	04	01	H7849_124_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	124	2	1	04	01	H7849_124_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	124	2	1	04	01	H7849_124_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	124	2	1	04	01	H7849_124_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	124	2	1	04	01	H7849_124_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.99	33						585.02	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	125	0	1	04	01	H7849_125_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	125	0	1	04	01	H7849_125_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	125	0	1	04	01	H7849_125_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	125	0	1	04	01	H7849_125_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	125	0	1	04	01	H7849_125_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	125	0	1	04	01	H7849_125_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											775.26	33						511.92	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	127	0	1	04	01	H7849_127_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	127	0	1	04	01	H7849_127_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	127	0	1	04	01	H7849_127_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	127	0	1	04	01	H7849_127_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	127	0	1	04	01	H7849_127_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	127	0	1	04	01	H7849_127_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.09	33						534.34	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	128	0	1	04	01	H7849_128_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	128	0	1	04	01	H7849_128_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	128	0	1	04	01	H7849_128_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H7849	128	0	1	04	01	H7849_128_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	128	0	1	04	01	H7849_128_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	128	0	1	04	01	H7849_128_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											708.34	33						534.52	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	129	0	1	04	01	H7849_129_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	129	0	1	04	01	H7849_129_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	129	0	1	04	01	H7849_129_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	129	0	1	04	01	H7849_129_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	129	0	1	04	01	H7849_129_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	129	0	1	04	01	H7849_129_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											707.11	33						534.26	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	130	0	1	04	01	H7849_130_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	130	0	1	04	01	H7849_130_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	130	0	1	04	01	H7849_130_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	130	0	1	04	01	H7849_130_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	130	0	1	04	01	H7849_130_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	130	0	1	04	01	H7849_130_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											580.96	28						414.86	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	131	0	1	04	01	H7849_131_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	131	0	1	04	01	H7849_131_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	131	0	1	04	01	H7849_131_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	131	0	1	04	01	H7849_131_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	131	0	1	04	01	H7849_131_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	131	0	1	04	01	H7849_131_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											581.01	28						450.69	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	132	0	1	04	01	H7849_132_0	6			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	132	0	1	04	01	H7849_132_0	6			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	132	0	1	04	01	H7849_132_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	132	0	1	04	01	H7849_132_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	132	0	1	04	01	H7849_132_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	132	0	1	04	01	H7849_132_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											581.01	28						450.69	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	133	1	1	04	01	H7849_133_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	133	1	1	04	01	H7849_133_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	133	1	1	04	01	H7849_133_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	133	1	1	04	01	H7849_133_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	133	1	1	04	01	H7849_133_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	133	1	1	04	01	H7849_133_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											899.35	33						588.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	133	2	1	04	01	H7849_133_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	133	2	1	04	01	H7849_133_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	133	2	1	04	01	H7849_133_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	133	2	1	04	01	H7849_133_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	133	2	1	04	01	H7849_133_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	133	2	1	04	01	H7849_133_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											899.35	33						588.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	133	3	1	04	01	H7849_133_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H7849	133	3	1	04	01	H7849_133_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	133	3	1	04	01	H7849_133_3	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H7849	133	3	1	04	01	H7849_133_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	133	3	1	04	01	H7849_133_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	133	3	1	04	01	H7849_133_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											899.35	33						588.96	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	134	1	1	04	01	H7849_134_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	134	1	1	04	01	H7849_134_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	134	1	1	04	01	H7849_134_1	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	134	1	1	04	01	H7849_134_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	134	1	1	04	01	H7849_134_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	134	1	1	04	01	H7849_134_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											511.21	33						718.68	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7849	134	2	1	04	01	H7849_134_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H7849	134	2	1	04	01	H7849_134_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H7849	134	2	1	04	01	H7849_134_2	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H7849	134	2	1	04	01	H7849_134_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	134	2	1	04	01	H7849_134_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7849	134	2	1	04	01	H7849_134_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											511.21	33						718.68	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H7917	009	0	1	04	01	H7917_009_0	5			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	009	0	1	04	01	H7917_009_0	5			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	009	0	1	04	01	H7917_009_0	5			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	009	0	1	04	01	H7917_009_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	009	0	1	04	01	H7917_009_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								55.00	110.00	145.00					50.00	100.00	125.00											55.00	110.00	145.00				50.00	100.00	125.00				55.00				55.00			1.83	1.67		1.83	1.67	1.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	009	0	1	04	01	H7917_009_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	010	0	1	04	01	H7917_010_0	5			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	010	0	1	04	01	H7917_010_0	5			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	010	0	1	04	01	H7917_010_0	5			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	010	0	1	04	01	H7917_010_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	010	0	1	04	01	H7917_010_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								55.00	110.00	145.00					50.00	100.00	125.00											55.00	110.00	145.00				50.00	100.00	125.00				55.00				55.00			1.83	1.67		1.83	1.67	1.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	010	0	1	04	01	H7917_010_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	011	0	1	04	01	H7917_011_0	5			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	011	0	1	04	01	H7917_011_0	5			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	011	0	1	04	01	H7917_011_0	5			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	011	0	1	04	01	H7917_011_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	011	0	1	04	01	H7917_011_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								55.00	110.00	145.00					50.00	100.00	125.00											55.00	110.00	145.00				50.00	100.00	125.00				55.00				55.00			1.83	1.67		1.83	1.67	1.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	011	0	1	04	01	H7917_011_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	012	0	1	04	01	H7917_012_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	012	0	1	04	01	H7917_012_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	012	0	1	04	01	H7917_012_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	012	0	1	04	01	H7917_012_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	012	0	1	04	01	H7917_012_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								70.00	140.00	185.00					65.00	130.00	165.00											70.00	140.00	185.00				65.00	130.00	165.00				70.00				70.00			2.33	2.17		2.33	2.17	2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	012	0	1	04	01	H7917_012_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	013	0	1	04	01	H7917_013_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	013	0	1	04	01	H7917_013_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	013	0	1	04	01	H7917_013_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	013	0	1	04	01	H7917_013_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	013	0	1	04	01	H7917_013_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								70.00	140.00	185.00					65.00	130.00	165.00											70.00	140.00	185.00				65.00	130.00	165.00				70.00				70.00			2.33	2.17		2.33	2.17	2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	013	0	1	04	01	H7917_013_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	014	0	1	04	01	H7917_014_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	014	0	1	04	01	H7917_014_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	014	0	1	04	01	H7917_014_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	014	0	1	04	01	H7917_014_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	014	0	1	04	01	H7917_014_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								70.00	140.00	185.00					65.00	130.00	165.00											70.00	140.00	185.00				65.00	130.00	165.00				70.00				70.00			2.33	2.17		2.33	2.17	2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	014	0	1	04	01	H7917_014_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	015	0	1	04	01	H7917_015_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	015	0	1	04	01	H7917_015_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	015	0	1	04	01	H7917_015_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	015	0	1	04	01	H7917_015_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								33.00	66.00	95.00					28.00	56.00	70.00											33.00	66.00	95.00				28.00	56.00	70.00				33.00				33.00			1.10	0.93		1.10	0.93	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													33.00	66.00	95.00	28.00	56.00	70.00	33.00	66.00	95.00	28.00	56.00	70.00	33.00		33.00
H7917	015	0	1	04	01	H7917_015_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								70.00	140.00	185.00					65.00	130.00	165.00											70.00	140.00	185.00				65.00	130.00	165.00				70.00				70.00			2.33	2.17		2.33	2.17	2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	015	0	1	04	01	H7917_015_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	030	0	1	04	01	H7917_030_0	5			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	030	0	1	04	01	H7917_030_0	5			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	030	0	1	04	01	H7917_030_0	5			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	35.00					10.00	10.00	10.00											15.00	30.00	35.00				10.00	10.00	10.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	030	0	1	04	01	H7917_030_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	135.00					42.00	84.00	105.00											47.00	94.00	135.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7917	030	0	1	04	01	H7917_030_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								99.00	198.00	290.00					94.00	188.00	230.00											99.00	198.00	290.00				94.00	188.00	230.00				99.00				99.00			3.30	3.13		3.30	3.13	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	030	0	1	04	01	H7917_030_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	031	0	1	04	01	H7917_031_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	031	0	1	04	01	H7917_031_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	031	0	1	04	01	H7917_031_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	35.00					10.00	10.00	10.00											15.00	30.00	35.00				10.00	10.00	10.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	031	0	1	04	01	H7917_031_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	135.00					42.00	84.00	105.00											47.00	94.00	135.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7917	031	0	1	04	01	H7917_031_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								99.00	198.00	290.00					94.00	188.00	230.00											99.00	198.00	290.00				94.00	188.00	230.00				99.00				99.00			3.30	3.13		3.30	3.13	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	031	0	1	04	01	H7917_031_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	032	0	1	04	01	H7917_032_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	032	0	1	04	01	H7917_032_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	032	0	1	04	01	H7917_032_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	35.00					10.00	10.00	10.00											15.00	30.00	35.00				10.00	10.00	10.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	032	0	1	04	01	H7917_032_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	135.00					42.00	84.00	105.00											47.00	94.00	135.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7917	032	0	1	04	01	H7917_032_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								99.00	198.00	290.00					94.00	188.00	230.00											99.00	198.00	290.00				94.00	188.00	230.00				99.00				99.00			3.30	3.13		3.30	3.13	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	032	0	1	04	01	H7917_032_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	033	0	1	04	01	H7917_033_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	033	0	1	04	01	H7917_033_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	033	0	1	04	01	H7917_033_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	35.00					10.00	10.00	10.00											15.00	30.00	35.00				10.00	10.00	10.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	033	0	1	04	01	H7917_033_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	135.00					42.00	84.00	105.00											47.00	94.00	135.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7917	033	0	1	04	01	H7917_033_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								99.00	198.00	290.00					94.00	188.00	230.00											99.00	198.00	290.00				94.00	188.00	230.00				99.00				99.00			3.30	3.13		3.30	3.13	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	033	0	1	04	01	H7917_033_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	034	0	1	04	01	H7917_034_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	034	0	1	04	01	H7917_034_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	034	0	1	04	01	H7917_034_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	034	0	1	04	01	H7917_034_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								40.00	80.00	100.00					35.00	70.00	90.00											40.00	80.00	100.00				35.00	70.00	90.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	90.00	35.00	70.00	100.00	35.00	70.00	90.00	35.00		35.00
H7917	034	0	1	04	01	H7917_034_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								85.00	170.00	215.00					80.00	160.00	200.00											85.00	170.00	215.00				80.00	160.00	200.00				85.00				85.00			2.83	2.67		2.83	2.67	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	034	0	1	04	01	H7917_034_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	035	0	1	04	01	H7917_035_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	035	0	1	04	01	H7917_035_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	035	0	1	04	01	H7917_035_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	035	0	1	04	01	H7917_035_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								40.00	80.00	100.00					35.00	70.00	90.00											40.00	80.00	100.00				35.00	70.00	90.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	90.00	35.00	70.00	100.00	35.00	70.00	90.00	35.00		35.00
H7917	035	0	1	04	01	H7917_035_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								85.00	170.00	215.00					80.00	160.00	200.00											85.00	170.00	215.00				80.00	160.00	200.00				85.00				85.00			2.83	2.67		2.83	2.67	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	035	0	1	04	01	H7917_035_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	036	0	1	04	01	H7917_036_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	036	0	1	04	01	H7917_036_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	036	0	1	04	01	H7917_036_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	036	0	1	04	01	H7917_036_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								40.00	80.00	100.00					35.00	70.00	90.00											40.00	80.00	100.00				35.00	70.00	90.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	90.00	35.00	70.00	100.00	35.00	70.00	90.00	35.00		35.00
H7917	036	0	1	04	01	H7917_036_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								85.00	170.00	215.00					80.00	160.00	200.00											85.00	170.00	215.00				80.00	160.00	200.00				85.00				85.00			2.83	2.67		2.83	2.67	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	036	0	1	04	01	H7917_036_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	037	0	1	04	01	H7917_037_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	037	0	1	04	01	H7917_037_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	037	0	1	04	01	H7917_037_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	25.00					5.00	5.00	5.00											10.00	20.00	25.00				5.00	5.00	5.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	037	0	1	04	01	H7917_037_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								40.00	80.00	100.00					35.00	70.00	90.00											40.00	80.00	100.00				35.00	70.00	90.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	100.00	35.00	70.00	90.00	35.00	70.00	100.00	35.00	70.00	90.00	35.00		35.00
H7917	037	0	1	04	01	H7917_037_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								85.00	170.00	215.00					80.00	160.00	200.00											85.00	170.00	215.00				80.00	160.00	200.00				85.00				85.00			2.83	2.67		2.83	2.67	2.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	037	0	1	04	01	H7917_037_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	038	0	1	04	01	H7917_038_0	5			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	038	0	1	04	01	H7917_038_0	5			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	038	0	1	04	01	H7917_038_0	5			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	35.00					10.00	10.00	10.00											15.00	30.00	35.00				10.00	10.00	10.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	038	0	1	04	01	H7917_038_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	135.00					42.00	84.00	105.00											47.00	94.00	135.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7917	038	0	1	04	01	H7917_038_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								99.00	198.00	290.00					94.00	188.00	230.00											99.00	198.00	290.00				94.00	188.00	230.00				99.00				99.00			3.30	3.13		3.30	3.13	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	038	0	1	04	01	H7917_038_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	040	0	1	04	01	H7917_040_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	040	0	1	04	01	H7917_040_0	4			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	15.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H7917	040	0	1	04	01	H7917_040_0	4			Generic	4	11	3	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	35.00					10.00	10.00	10.00											15.00	30.00	35.00				10.00	10.00	10.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	040	0	1	04	01	H7917_040_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	135.00					42.00	84.00	105.00											47.00	94.00	135.00				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7917	040	0	1	04	01	H7917_040_0	4			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								99.00	198.00	290.00					94.00	188.00	230.00											99.00	198.00	290.00				94.00	188.00	230.00				99.00				99.00			3.30	3.13		3.30	3.13	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7917	040	0	1	04	01	H7917_040_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H7925	002	0	1	01	01	H7925_002_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7925	002	0	1	01	01	H7925_002_0	18			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H7925	002	0	1	01	01	H7925_002_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7925	002	0	1	01	01	H7925_002_0	18			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H7925	002	0	1	01	01	H7925_002_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H7925	002	0	1	01	01	H7925_002_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											84.84	50	50	50				84.84	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H7925	002	0	1	01	01	H7925_002_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H7925	002	0	1	01	01	H7925_002_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H7925	002	0	1	01	01	H7925_002_0	18			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H7993	001	0	1	01	01	H7993_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	001	0	1	01	01	H7993_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	001	0	1	01	01	H7993_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	001	0	1	01	01	H7993_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7993	001	0	1	01	01	H7993_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	100.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	100.00				35.00		35.00
H7993	001	0	1	01	01	H7993_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	80.00	160.00	240.00																			80.00	160.00	240.00																80.00				80.00		2.67			2.67			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	001	0	1	01	01	H7993_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	002	0	1	01	01	H7993_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	002	0	1	01	01	H7993_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	002	0	1	01	01	H7993_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	002	0	1	01	01	H7993_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7993	002	0	1	01	01	H7993_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	100.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	100.00				35.00		35.00
H7993	002	0	1	01	01	H7993_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	80.00	160.00	240.00																			80.00	160.00	240.00																80.00				80.00		2.67			2.67			2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	002	0	1	01	01	H7993_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	003	0	1	01	01	H7993_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	003	0	1	01	01	H7993_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	003	0	1	01	01	H7993_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	003	0	1	01	01	H7993_003_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7993	003	0	1	01	01	H7993_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	100.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	100.00				35.00		35.00
H7993	003	0	1	01	01	H7993_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	297.00																99.00				99.00		3.30			3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	003	0	1	01	01	H7993_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	004	0	1	01	01	H7993_004_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	004	0	1	01	01	H7993_004_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	004	0	1	01	01	H7993_004_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	004	0	1	01	01	H7993_004_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7993	004	0	1	01	01	H7993_004_0	11			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	004	0	1	01	01	H7993_004_0	11			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	004	0	1	01	01	H7993_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	005	0	1	01	01	H7993_005_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	005	0	1	01	01	H7993_005_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	005	0	1	01	01	H7993_005_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	005	0	1	01	01	H7993_005_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7993	005	0	1	01	01	H7993_005_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	100.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	100.00				35.00		35.00
H7993	005	0	1	01	01	H7993_005_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	99.00	198.00	297.00																			99.00	198.00	297.00																99.00				99.00		3.30			3.30			3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	005	0	1	01	01	H7993_005_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	006	0	1	01	01	H7993_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	006	0	1	01	01	H7993_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	006	0	1	01	01	H7993_006_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00				7.00	14.00	17.50				7.00		7.00
H7993	006	0	1	01	01	H7993_006_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	17.50																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7993	006	0	1	01	01	H7993_006_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	006	0	1	01	01	H7993_006_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	006	0	1	01	01	H7993_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	007	0	1	01	01	H7993_007_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	007	0	1	01	01	H7993_007_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	007	0	1	01	01	H7993_007_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	007	0	1	01	01	H7993_007_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H7993	007	0	1	01	01	H7993_007_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	007	0	1	01	01	H7993_007_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	007	0	1	01	01	H7993_007_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H7993	008	0	1	01	01	H7993_008_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	008	0	1	01	01	H7993_008_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H7993	008	0	1	01	01	H7993_008_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H7993	008	0	1	01	01	H7993_008_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H7993	008	0	1	01	01	H7993_008_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	008	0	1	01	01	H7993_008_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H7993	008	0	1	01	01	H7993_008_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8003	001	0	1	04	01	H8003_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	001	0	1	04	01	H8003_001_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	001	0	1	04	01	H8003_001_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	001	0	1	04	01	H8003_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8003	001	0	1	04	01	H8003_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	001	0	1	04	01	H8003_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	001	0	1	04	01	H8003_001_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	001	0	1	04	01	H8003_001_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	002	0	1	04	01	H8003_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	002	0	1	04	01	H8003_002_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	002	0	1	04	01	H8003_002_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	002	0	1	04	01	H8003_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8003	002	0	1	04	01	H8003_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	002	0	1	04	01	H8003_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	002	0	1	04	01	H8003_002_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	002	0	1	04	01	H8003_002_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	003	0	1	04	01	H8003_003_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	003	0	1	04	01	H8003_003_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	003	0	1	04	01	H8003_003_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	003	0	1	04	01	H8003_003_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8003	003	0	1	04	01	H8003_003_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	003	0	1	04	01	H8003_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	003	0	1	04	01	H8003_003_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	003	0	1	04	01	H8003_003_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	004	0	1	04	01	H8003_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	004	0	1	04	01	H8003_004_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	004	0	1	04	01	H8003_004_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	004	0	1	04	01	H8003_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8003	004	0	1	04	01	H8003_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	004	0	1	04	01	H8003_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	004	0	1	04	01	H8003_004_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	004	0	1	04	01	H8003_004_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	005	0	1	04	01	H8003_005_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	005	0	1	04	01	H8003_005_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	005	0	1	04	01	H8003_005_0	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	005	0	1	04	01	H8003_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8003	005	0	1	04	01	H8003_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	005	0	1	04	01	H8003_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	005	0	1	04	01	H8003_005_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	005	0	1	04	01	H8003_005_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	006	0	1	04	01	H8003_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	006	0	1	04	01	H8003_006_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8003	006	0	1	04	01	H8003_006_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					10.00	20.00	30.00					10.00	20.00	0.00																15.00				10.00			0.50	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	006	0	1	04	01	H8003_006_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8003	006	0	1	04	01	H8003_006_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	006	0	1	04	01	H8003_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	006	0	1	04	01	H8003_006_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8003	006	0	1	04	01	H8003_006_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8010	002	0	1	01	01	H8010_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8010	002	0	1	01	01	H8010_002_0	11			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8010	002	0	1	01	01	H8010_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	135.00																					125.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H8010	002	0	1	01	01	H8010_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					275.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H8010	002	0	1	01	01	H8010_002_0	11			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					33	33	33																				33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H8010	003	0	1	01	01	H8010_003_0	9			Preferred Generic	4	11	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8010	003	0	1	01	01	H8010_003_0	9			Generic	4	11	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	8.00	16.00	24.00																					0.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8010	003	0	1	01	01	H8010_003_0	9			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				51.95	23	23	23																				22															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H8010	003	0	1	01	01	H8010_003_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				92.10	34	34	34																				30															34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H8010	003	0	1	01	01	H8010_003_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H8014	001	0	1	04	01	H8014_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	0.00					0.00	0.00	0.00											9.00	18.00	0.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8014	001	0	1	04	01	H8014_001_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								14.00	28.00	42.00					0.00	0.00	0.00											14.00	28.00	42.00				0.00	0.00	0.00				14.00				14.00			0.47	0.00		0.47	0.00	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8014	001	0	1	04	01	H8014_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H8014	001	0	1	04	01	H8014_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8014	001	0	1	04	01	H8014_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											960.95	33						960.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8014	002	0	1	04	01	H8014_002_0	10			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8014	002	0	1	04	01	H8014_002_0	10			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8014	002	0	1	04	01	H8014_002_0	10			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H8014	002	0	1	04	01	H8014_002_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8014	002	0	1	04	01	H8014_002_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											960.95	33						960.95	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8019	002	0	1	02	01	H8019_002_0	6			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	002	0	1	02	01	H8019_002_0	6			Preferred Generic	4	01	1	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	002	0	1	02	01	H8019_002_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H8019	002	0	1	02	01	H8019_002_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H8019	002	0	1	02	01	H8019_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	002	0	1	02	01	H8019_002_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												33							33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	002	0	1	02	01	H8019_002_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	002	0	1	02	01	H8019_002_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	006	0	1	01	01	H8019_006_0	5			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	006	0	1	01	01	H8019_006_0	5			Preferred Generic	4	01	1	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	006	0	1	01	01	H8019_006_0	5			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H8019	006	0	1	01	01	H8019_006_0	5			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H8019	006	0	1	01	01	H8019_006_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	006	0	1	01	01	H8019_006_0	5			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												33							33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	006	0	1	01	01	H8019_006_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	006	0	1	01	01	H8019_006_0	5			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	007	0	1	02	01	H8019_007_0	6			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	007	0	1	02	01	H8019_007_0	6			Preferred Generic	4	01	1	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	007	0	1	02	01	H8019_007_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H8019	007	0	1	02	01	H8019_007_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H8019	007	0	1	02	01	H8019_007_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	007	0	1	02	01	H8019_007_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												33							33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	007	0	1	02	01	H8019_007_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	007	0	1	02	01	H8019_007_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	008	0	1	02	01	H8019_008_0	7			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	008	0	1	02	01	H8019_008_0	7			Preferred Generic	4	01	1	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8019	008	0	1	02	01	H8019_008_0	7			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H8019	008	0	1	02	01	H8019_008_0	7			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H8019	008	0	1	02	01	H8019_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	008	0	1	02	01	H8019_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												30							30						30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	008	0	1	02	01	H8019_008_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H8019	008	0	1	02	01	H8019_008_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H8026	001	0	1	48	05	H8026_001_0	4			Generic Drugs	4	11		2	1	1	111		10	111		1	30	60	90				2	2	30	60	90					29	31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8026	001	0	1	48	05	H8026_001_0	4			Brand Drugs	4	11		2	2	1	111		10	111		1	30	60	90				2	2	30	60	90					29	31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8026	001	0	1	48	05	H8026_001_0	4			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		10	000		1	30	60	90				1	2								29	31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00			0.00	0.00																		
H8046	001	0	1	48	05	H8046_001_0	5			Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8046	001	0	1	48	05	H8046_001_0	5			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8046	001	0	1	48	05	H8046_001_0	5			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31								31						31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8064	002	0	1	04	01	H8064_002_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8064	002	0	1	04	01	H8064_002_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	6.00																			2.00	4.00	0.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8064	002	0	1	04	01	H8064_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	15.00	30.00	45.00																			15.00	30.00	37.50																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00				15.00	30.00	37.50				15.00		15.00
H8064	002	0	1	04	01	H8064_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00
H8064	002	0	1	04	01	H8064_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				75.04	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8064	002	0	1	04	01	H8064_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	001	0	1	04	01	H8070_001_0	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	001	0	1	04	01	H8070_001_0	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	12.00	24.00	36.00																			12.00	24.00	24.00																	12.00			12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	001	0	1	04	01	H8070_001_0	7			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8070	001	0	1	04	01	H8070_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	001	0	1	04	01	H8070_001_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2336.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	002	0	1	04	01	H8070_002_0	8			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	002	0	1	04	01	H8070_002_0	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	002	0	1	04	01	H8070_002_0	8			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8070	002	0	1	04	01	H8070_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8070	002	0	1	04	01	H8070_002_0	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2329.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8095	001	0	1	01	01	H8095_001_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				0.00			0.33	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		0.00
H8095	001	0	1	01	01	H8095_001_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	20.00	28.00					10.00	20.00	0.00																20.00				10.00			0.67	0.33	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	28.00	10.00	20.00	0.00				20.00		10.00
H8095	001	0	1	01	01	H8095_001_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					47.00	94.00	129.00					47.00	94.00	118.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8095	001	0	1	01	01	H8095_001_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	275.00					100.00	200.00	250.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8095	001	0	1	01	01	H8095_001_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1598.77	33						1280.43	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H8133	001	0	1	01	01	H8133_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8133	001	0	1	01	01	H8133_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8133	001	0	1	01	01	H8133_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8133	001	0	1	01	01	H8133_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8133	001	0	1	01	01	H8133_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8133	001	0	1	01	01	H8133_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8133	005	0	1	01	01	H8133_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8133	005	0	1	01	01	H8133_005_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8133	005	0	1	01	01	H8133_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8133	005	0	1	01	01	H8133_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8133	005	0	1	01	01	H8133_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	001	0	1	02	01	H8142_001_0	17			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	001	0	1	02	01	H8142_001_0	17			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					13.00	26.00	26.00					0.00	0.00	0.00																20.00				20.00			0.67	0.43	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	26.00	0.00	0.00	0.00				20.00		20.00
H8142	001	0	1	02	01	H8142_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	94.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	001	0	1	02	01	H8142_001_0	17			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	200.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	001	0	1	02	01	H8142_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	002	0	1	02	01	H8142_002_0	17			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								8.00	16.00	24.00					0.00	0.00	0.00					0.00	0.00	0.00																8.00				8.00			0.27	0.00	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	002	0	1	02	01	H8142_002_0	17			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					8.00	16.00	16.00					0.00	0.00	0.00																15.00				15.00			0.50	0.27	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	8.00	16.00	16.00	0.00	0.00	0.00				15.00		15.00
H8142	002	0	1	02	01	H8142_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								45.00	90.00	135.00					45.00	90.00	90.00					45.00	90.00	90.00																45.00				45.00			1.50	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	002	0	1	02	01	H8142_002_0	17			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								95.00	190.00	285.00					95.00	190.00	190.00					95.00	190.00	190.00																95.00				95.00			3.17	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	002	0	1	02	01	H8142_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	003	0	1	02	01	H8142_003_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								7.00	14.00	21.00					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	003	0	1	02	01	H8142_003_0	10			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								12.00	24.00	36.00					5.00	10.00	10.00					0.00	0.00	0.00																12.00				12.00			0.40	0.17	0.00			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	5.00	10.00	10.00	0.00	0.00	0.00				12.00		12.00
H8142	003	0	1	02	01	H8142_003_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								45.00	90.00	135.00					45.00	90.00	90.00					45.00	90.00	90.00																45.00				45.00			1.50	1.50	1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	003	0	1	02	01	H8142_003_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								95.00	190.00	285.00					95.00	190.00	190.00					95.00	190.00	190.00																95.00				95.00			3.17	3.17	3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	003	0	1	02	01	H8142_003_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											620.00	33						620.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	007	0	1	02	01	H8142_007_0	20			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8142	007	0	1	02	01	H8142_007_0	20			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					13.00	26.00	26.00					0.00	0.00	0.00																20.00				20.00			0.67	0.43	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	26.00	0.00	0.00	0.00				20.00		20.00
H8142	007	0	1	02	01	H8142_007_0	20			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	94.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	007	0	1	02	01	H8142_007_0	20			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	200.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00				35.00		35.00
H8142	007	0	1	02	01	H8142_007_0	20			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8145	004	0	1	09	04	H8145_004_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
H8145	004	0	1	09	04	H8145_004_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H8145	004	0	1	09	04	H8145_004_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	004	0	1	09	04	H8145_004_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	004	0	1	09	04	H8145_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	006	0	1	09	04	H8145_006_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H8145	006	0	1	09	04	H8145_006_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H8145	006	0	1	09	04	H8145_006_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	006	0	1	09	04	H8145_006_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	006	0	1	09	04	H8145_006_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	032	0	1	09	04	H8145_032_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0				0.33	0	0	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H8145	032	0	1	09	04	H8145_032_0	4			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0				0.33	0	0	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8145	032	0	1	09	04	H8145_032_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H8145	032	0	1	09	04	H8145_032_0	4			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8145	032	0	1	09	04	H8145_032_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	032	0	1	09	04	H8145_032_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	032	0	1	09	04	H8145_032_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	052	0	1	09	04	H8145_052_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H8145	052	0	1	09	04	H8145_052_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H8145	052	0	1	09	04	H8145_052_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	052	0	1	09	04	H8145_052_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	052	0	1	09	04	H8145_052_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	069	0	1	09	04	H8145_069_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H8145	069	0	1	09	04	H8145_069_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H8145	069	0	1	09	04	H8145_069_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	069	0	1	09	04	H8145_069_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	069	0	1	09	04	H8145_069_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	084	0	1	09	04	H8145_084_0	11			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H8145	084	0	1	09	04	H8145_084_0	11			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8145	084	0	1	09	04	H8145_084_0	11			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
H8145	084	0	1	09	04	H8145_084_0	11			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8145	084	0	1	09	04	H8145_084_0	11			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	084	0	1	09	04	H8145_084_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	084	0	1	09	04	H8145_084_0	11			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	091	0	1	09	04	H8145_091_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H8145	091	0	1	09	04	H8145_091_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
H8145	091	0	1	09	04	H8145_091_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	091	0	1	09	04	H8145_091_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	091	0	1	09	04	H8145_091_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	122	0	1	09	04	H8145_122_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H8145	122	0	1	09	04	H8145_122_0	4			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8145	122	0	1	09	04	H8145_122_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H8145	122	0	1	09	04	H8145_122_0	4			Generic	4	11	1	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8145	122	0	1	09	04	H8145_122_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	122	0	1	09	04	H8145_122_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	122	0	1	09	04	H8145_122_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8145	123	0	1	09	04	H8145_123_0	4			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
H8145	123	0	1	09	04	H8145_123_0	4			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H8145	123	0	1	09	04	H8145_123_0	4			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		90.00	35.00		35.00
H8145	123	0	1	09	04	H8145_123_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		200.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8145	123	0	1	09	04	H8145_123_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8166	001	0	1	04	01	H8166_001_0	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	001	0	1	04	01	H8166_001_0	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	001	0	1	04	01	H8166_001_0	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	001	0	1	04	01	H8166_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	001	0	1	04	01	H8166_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1185.42	33						1185.42	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	002	0	1	04	01	H8166_002_0	8			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	002	0	1	04	01	H8166_002_0	8			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	002	0	1	04	01	H8166_002_0	8			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	002	0	1	04	01	H8166_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	002	0	1	04	01	H8166_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1241.45	33						1241.45	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	004	0	1	04	01	H8166_004_0	10			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	004	0	1	04	01	H8166_004_0	10			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					5.00		15.00													45.00						0.00				15.00				15.00			0.48	0.16				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8166	004	0	1	04	01	H8166_004_0	10			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								47.00		141.00					47.00		141.00													141.00						120.00				47.00				47.00			1.52	1.52				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	004	0	1	04	01	H8166_004_0	10			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				31		90	1	2						90	31		31								100.00		300.00					100.00		300.00													300.00						275.00				100.00				100.00			3.23	3.23				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
H8166	004	0	1	04	01	H8166_004_0	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1414.02	33						1414.02	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8173	001	0	1	01	01	H8173_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	001	0	1	01	01	H8173_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	001	0	1	01	01	H8173_001_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H8173	001	0	1	01	01	H8173_001_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H8173	001	0	1	01	01	H8173_001_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	001	0	1	01	01	H8173_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	001	0	1	01	01	H8173_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8173	002	0	1	01	01	H8173_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	002	0	1	01	01	H8173_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	002	0	1	01	01	H8173_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H8173	002	0	1	01	01	H8173_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H8173	002	0	1	01	01	H8173_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	002	0	1	01	01	H8173_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	002	0	1	01	01	H8173_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8173	007	0	1	01	01	H8173_007_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	007	0	1	01	01	H8173_007_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	007	0	1	01	01	H8173_007_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H8173	007	0	1	01	01	H8173_007_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H8173	007	0	1	01	01	H8173_007_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	007	0	1	01	01	H8173_007_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	007	0	1	01	01	H8173_007_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8173	011	0	1	01	01	H8173_011_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	011	0	1	01	01	H8173_011_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	011	0	1	01	01	H8173_011_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	011	0	1	01	01	H8173_011_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H8173	011	0	1	01	01	H8173_011_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	011	0	1	01	01	H8173_011_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	95.00	190.00	285.00																			95.00	190.00	285.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	011	0	1	01	01	H8173_011_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8173	013	0	1	01	01	H8173_013_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	013	0	1	01	01	H8173_013_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	013	0	1	01	01	H8173_013_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H8173	013	0	1	01	01	H8173_013_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H8173	013	0	1	01	01	H8173_013_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	105.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	013	0	1	01	01	H8173_013_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	90.00	180.00	270.00																			90.00	180.00	270.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	013	0	1	01	01	H8173_013_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8173	016	0	1	01	01	H8173_016_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	016	0	1	01	01	H8173_016_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	016	0	1	01	01	H8173_016_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	016	0	1	01	01	H8173_016_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H8173	016	0	1	01	01	H8173_016_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	016	0	1	01	01	H8173_016_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	016	0	1	01	01	H8173_016_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8173	019	0	1	01	01	H8173_019_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8173	019	0	1	01	01	H8173_019_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H8173	019	0	1	01	01	H8173_019_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H8173	019	0	1	01	01	H8173_019_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H8173	019	0	1	01	01	H8173_019_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	019	0	1	01	01	H8173_019_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8173	019	0	1	01	01	H8173_019_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H8176	003	0	1	01	01	H8176_003_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8176	003	0	1	01	01	H8176_003_0	6			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8176	003	0	1	01	01	H8176_003_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H8176	003	0	1	01	01	H8176_003_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8176	003	0	1	01	01	H8176_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1191.81	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H8176	003	0	1	01	01	H8176_003_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8181	001	0	1	04	01	H8181_001_0	6			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			2.00	4.00	0.00																0.00				0.00		0.00			0.07			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				2.00	4.00	0.00				0.00		0.00
H8181	001	0	1	04	01	H8181_001_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	0.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00				14.00	28.00	0.00				14.00		14.00
H8181	001	0	1	04	01	H8181_001_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8181	001	0	1	04	01	H8181_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8181	001	0	1	04	01	H8181_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				906.80	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8181	002	0	1	04	01	H8181_002_0	6			Preferred Generic	4	01	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			2.00	4.00	0.00																0.00				0.00		0.00			0.07			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				2.00	4.00	0.00				0.00		0.00
H8181	002	0	1	04	01	H8181_002_0	6			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	0.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00				14.00	28.00	0.00				14.00		14.00
H8181	002	0	1	04	01	H8181_002_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8181	002	0	1	04	01	H8181_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8181	002	0	1	04	01	H8181_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1129.54	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8197	002	1	1	48	05	H8197_002_1	4			Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8197	002	1	1	48	05	H8197_002_1	4			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8197	002	1	1	48	05	H8197_002_1	4			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31								31						31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8197	002	2	1	48	05	H8197_002_2	6			Generic Drugs	4	01		2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8197	002	2	1	48	05	H8197_002_2	6			Brand Drugs	4	11		2	2	1	111		01	111		1	31	60	90				2	2	31	60	90				31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8197	002	2	1	48	05	H8197_002_2	6			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	010		01	010		1	31								31						31		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8211	001	0	1	04	01	H8211_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	001	0	1	04	01	H8211_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8211	001	0	1	04	01	H8211_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	001	0	1	04	01	H8211_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8211	001	0	1	04	01	H8211_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	001	0	1	04	01	H8211_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	001	0	1	04	01	H8211_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				440.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	002	0	1	04	01	H8211_002_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	002	0	1	04	01	H8211_002_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8211	002	0	1	04	01	H8211_002_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	002	0	1	04	01	H8211_002_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8211	002	0	1	04	01	H8211_002_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	002	0	1	04	01	H8211_002_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	002	0	1	04	01	H8211_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				503.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	006	0	1	04	01	H8211_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	006	0	1	04	01	H8211_006_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8211	006	0	1	04	01	H8211_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	006	0	1	04	01	H8211_006_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8211	006	0	1	04	01	H8211_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	006	0	1	04	01	H8211_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	006	0	1	04	01	H8211_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				276.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	007	0	1	04	01	H8211_007_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	007	0	1	04	01	H8211_007_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8211	007	0	1	04	01	H8211_007_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	007	0	1	04	01	H8211_007_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8211	007	0	1	04	01	H8211_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	007	0	1	04	01	H8211_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	007	0	1	04	01	H8211_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				461.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	009	0	1	04	01	H8211_009_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	009	0	1	04	01	H8211_009_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8211	009	0	1	04	01	H8211_009_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	15.00		45.00																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	009	0	1	04	01	H8211_009_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	15.00		45.00																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8211	009	0	1	04	01	H8211_009_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	009	0	1	04	01	H8211_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	009	0	1	04	01	H8211_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				690.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	011	0	1	04	01	H8211_011_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	011	0	1	04	01	H8211_011_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8211	011	0	1	04	01	H8211_011_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8211	011	0	1	04	01	H8211_011_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8211	011	0	1	04	01	H8211_011_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	011	0	1	04	01	H8211_011_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8211	011	0	1	04	01	H8211_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				446.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8213	001	0	1	48	05	H8213_001_0	5			Generic Drugs	4	01		2	1	1	111		01	100		1	30	60	100				1	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8213	001	0	1	48	05	H8213_001_0	5			Brand Drugs	4	11		2	2	1	111		01	100		1	30	60	100				1	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8213	001	0	1	48	05	H8213_001_0	5			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	100		1	30	60	100				1	2			100				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8225	003	0	1	01	01	H8225_003_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8225	003	0	1	01	01	H8225_003_0	17			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H8225	003	0	1	01	01	H8225_003_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8225	003	0	1	01	01	H8225_003_0	17			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8225	003	0	1	01	01	H8225_003_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H8225	003	0	1	01	01	H8225_003_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.96	50	50	50				81.96	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8225	003	0	1	01	01	H8225_003_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H8225	003	0	1	01	01	H8225_003_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8225	003	0	1	01	01	H8225_003_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H8244	002	0	1	04	01	H8244_002_0	15			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8244	002	0	1	04	01	H8244_002_0	15			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8244	002	0	1	04	01	H8244_002_0	15			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8244	002	0	1	04	01	H8244_002_0	15			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8244	002	0	1	04	01	H8244_002_0	15			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8244	002	0	1	04	01	H8244_002_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				659.75	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8244	002	0	1	04	01	H8244_002_0	15			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8244	002	0	1	04	01	H8244_002_0	15			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8293	001	0	1	01	01	H8293_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8293	001	0	1	01	01	H8293_001_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8293	001	0	1	01	01	H8293_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H8293	001	0	1	01	01	H8293_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	30.00	70.00	105.00	35.00		35.00
H8293	001	0	1	01	01	H8293_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											854.08	33						854.08	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8293	002	0	1	01	01	H8293_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8293	002	0	1	01	01	H8293_002_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	50.00					0.00	0.00	0.00											20.00	40.00	50.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8293	002	0	1	01	01	H8293_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H8293	002	0	1	01	01	H8293_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8293	002	0	1	01	01	H8293_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.82	29						589.82	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	001	0	1	01	01	H8332_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	001	0	1	01	01	H8332_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	001	0	1	01	01	H8332_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	001	0	1	01	01	H8332_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	001	0	1	01	01	H8332_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8332	001	0	1	01	01	H8332_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	001	0	1	01	01	H8332_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											841.21	33						647.14	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8332	002	0	1	01	01	H8332_002_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	002	0	1	01	01	H8332_002_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	002	0	1	01	01	H8332_002_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	002	0	1	01	01	H8332_002_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	002	0	1	01	01	H8332_002_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8332	002	0	1	01	01	H8332_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	002	0	1	01	01	H8332_002_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1043.51	33						695.43	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8332	003	0	1	01	01	H8332_003_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	003	0	1	01	01	H8332_003_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	003	0	1	01	01	H8332_003_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	003	0	1	01	01	H8332_003_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	003	0	1	01	01	H8332_003_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8332	003	0	1	01	01	H8332_003_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	003	0	1	01	01	H8332_003_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											723.03	30						557.91	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8332	004	0	1	01	01	H8332_004_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	004	0	1	01	01	H8332_004_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	004	0	1	01	01	H8332_004_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	004	0	1	01	01	H8332_004_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	004	0	1	01	01	H8332_004_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8332	004	0	1	01	01	H8332_004_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	004	0	1	01	01	H8332_004_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											820.51	33						658.22	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8332	005	0	1	01	01	H8332_005_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	005	0	1	01	01	H8332_005_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	005	0	1	01	01	H8332_005_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	005	0	1	01	01	H8332_005_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8332	005	0	1	01	01	H8332_005_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8332	005	0	1	01	01	H8332_005_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8332	005	0	1	01	01	H8332_005_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											786.70	30						585.83	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8385	001	0	1	04	01	H8385_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				0.00				0.00			0.07	0.00		0.07	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	001	0	1	04	01	H8385_001_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				4.00				4.00			0.33	0.13		0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	001	0	1	04	01	H8385_001_0	7			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				42.00				42.00			1.57	1.40		1.57	1.40	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	001	0	1	04	01	H8385_001_0	7			Non-Preferred Drug	4	10	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	001	0	1	04	01	H8385_001_0	7			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31												30	30	30					30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	001	0	1	04	01	H8385_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	002	0	1	04	01	H8385_002_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	002	0	1	04	01	H8385_002_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	002	0	1	04	01	H8385_002_0	8			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	002	0	1	04	01	H8385_002_0	8			Non-Preferred Drug	4	10	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	002	0	1	04	01	H8385_002_0	8			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31												30	30	30					30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	002	0	1	04	01	H8385_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	003	0	1	04	01	H8385_003_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	003	0	1	04	01	H8385_003_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					4.00	8.00	12.00											8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00			0.27	0.13		0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	003	0	1	04	01	H8385_003_0	7			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	003	0	1	04	01	H8385_003_0	7			Non-Preferred Drug	4	10	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	003	0	1	04	01	H8385_003_0	7			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31												30	30	30					30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	003	0	1	04	01	H8385_003_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	004	0	1	04	01	H8385_004_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	004	0	1	04	01	H8385_004_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	004	0	1	04	01	H8385_004_0	8			Preferred Brand	4	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	004	0	1	04	01	H8385_004_0	8			Non-Preferred Drug	4	10	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8385	004	0	1	04	01	H8385_004_0	8			Specialty Tier	4	11	1	1	5	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31												30	30	30					30	30	30										30	30	30				30	30	30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8385	004	0	1	04	01	H8385_004_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8390	015	0	1	01	01	H8390_015_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8390	015	0	1	01	01	H8390_015_0	7		N	Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	102				1	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8390	015	0	1	01	01	H8390_015_0	7		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31				5.92	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8390	015	0	1	01	01	H8390_015_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31				87.37	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8390	015	0	1	01	01	H8390_015_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31				56.73	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8390	015	0	1	01	01	H8390_015_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				667.94	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H8390	016	0	1	01	01	H8390_016_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8390	016	0	1	01	01	H8390_016_0	7		N	Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	102				1	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8390	016	0	1	01	01	H8390_016_0	7		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31				5.99	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8390	016	0	1	01	01	H8390_016_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31				95.94	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8390	016	0	1	01	01	H8390_016_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31				62.78	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8390	016	0	1	01	01	H8390_016_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				712.11	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
H8432	009	0	1	01	01	H8432_009_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	009	0	1	01	01	H8432_009_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					10.00	30.00	30.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	009	0	1	01	01	H8432_009_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8432	009	0	1	01	01	H8432_009_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8432	009	0	1	01	01	H8432_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	010	0	1	01	01	H8432_010_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	010	0	1	01	01	H8432_010_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					15.00	45.00	45.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	010	0	1	01	01	H8432_010_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	120.00	120.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	010	0	1	01	01	H8432_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	010	0	1	01	01	H8432_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	011	0	1	01	01	H8432_011_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	011	0	1	01	01	H8432_011_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					15.00	45.00	45.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	011	0	1	01	01	H8432_011_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	011	0	1	01	01	H8432_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	011	0	1	01	01	H8432_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	016	0	1	01	01	H8432_016_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					4.00	12.00	12.00																9.00				9.00			0.30	0.13	0.13			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8432	016	0	1	01	01	H8432_016_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					10.00	30.00	30.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8432	016	0	1	01	01	H8432_016_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	016	0	1	01	01	H8432_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8432	016	0	1	01	01	H8432_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8432	016	0	1	01	01	H8432_016_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8432	016	0	1	01	01	H8432_016_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8432	038	1	1	01	01	H8432_038_1	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	038	1	1	01	01	H8432_038_1	7			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					10.00	30.00	30.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	038	1	1	01	01	H8432_038_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	111.00	111.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	038	1	1	01	01	H8432_038_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	038	1	1	01	01	H8432_038_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	038	2	1	01	01	H8432_038_2	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	038	2	1	01	01	H8432_038_2	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					10.00	30.00	30.00																15.00				15.00			0.50	0.33	0.33			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	038	2	1	01	01	H8432_038_2	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	111.00	111.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	038	2	1	01	01	H8432_038_2	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	038	2	1	01	01	H8432_038_2	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	040	0	1	01	01	H8432_040_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	040	0	1	01	01	H8432_040_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					15.00	45.00	45.00																20.00				20.00			0.67	0.50	0.50			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8432	040	0	1	01	01	H8432_040_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8432	040	0	1	01	01	H8432_040_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								99.00	198.00	297.00					94.00	188.00	282.00					94.00	282.00	282.00																99.00				99.00			3.30	3.13	3.13			2.91	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35		35
H8432	040	0	1	01	01	H8432_040_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8452	001	0	1	48	05	H8452_001_0	4			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8452	001	0	1	48	05	H8452_001_0	4			Brand Drugs	4	11		2	2	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8452	001	0	1	48	05	H8452_001_0	4			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8458	003	0	1	04	01	H8458_003_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8458	003	0	1	04	01	H8458_003_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8458	003	0	1	04	01	H8458_003_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H8458	003	0	1	04	01	H8458_003_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.25	49	49	49				98.25	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8458	003	0	1	04	01	H8458_003_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H8458	003	0	1	04	01	H8458_003_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8547	001	0	1	01	01	H8547_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8547	001	0	1	01	01	H8547_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8547	001	0	1	01	01	H8547_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8547	001	0	1	01	01	H8547_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8547	001	0	1	01	01	H8547_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8547	001	0	1	01	01	H8547_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8552	020	0	1	04	01	H8552_020_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	020	0	1	04	01	H8552_020_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	020	0	1	04	01	H8552_020_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8552	020	0	1	04	01	H8552_020_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	020	0	1	04	01	H8552_020_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	020	0	1	04	01	H8552_020_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	028	0	1	04	01	H8552_028_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								6.00	12.00	18.00					1.00	2.00	3.00					0.00	0.00	0.00																6.00				6.00			0.20	0.03	0.00			0.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	028	0	1	04	01	H8552_028_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								11.00	22.00	33.00					6.00	12.00	18.00					0.00	0.00	0.00																11.00				11.00			0.37	0.20	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	028	0	1	04	01	H8552_028_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8552	028	0	1	04	01	H8552_028_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	028	0	1	04	01	H8552_028_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	028	0	1	04	01	H8552_028_0	5			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	028	0	1	04	01	H8552_028_0	5			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8552	029	0	1	04	01	H8552_029_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	029	0	1	04	01	H8552_029_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								17.00	34.00	51.00					12.00	24.00	36.00					0.00	0.00	0.00																17.00				17.00			0.57	0.40	0.00			0.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	029	0	1	04	01	H8552_029_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H8552	029	0	1	04	01	H8552_029_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	029	0	1	04	01	H8552_029_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8552	029	0	1	04	01	H8552_029_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8553	001	0	1	04	01	H8553_001_0	19			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8553	001	0	1	04	01	H8553_001_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8553	001	0	1	04	01	H8553_001_0	19			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H8553	001	0	1	04	01	H8553_001_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.64	40	40	40				97.64	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8553	001	0	1	04	01	H8553_001_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H8553	001	0	1	04	01	H8553_001_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8553	001	0	1	04	01	H8553_001_0	19			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H8554	001	0	1	01	01	H8554_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8554	001	0	1	01	01	H8554_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8554	001	0	1	01	01	H8554_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8554	001	0	1	01	01	H8554_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8554	001	0	1	01	01	H8554_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8554	001	0	1	01	01	H8554_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8554	004	0	1	01	01	H8554_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8554	004	0	1	01	01	H8554_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8554	004	0	1	01	01	H8554_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8554	004	0	1	01	01	H8554_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8554	004	0	1	01	01	H8554_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	001	0	1	01	01	H8578_001_0	9			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	001	0	1	01	01	H8578_001_0	9			Preferred Generic	4	11	1	2	1	3		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8578	001	0	1	01	01	H8578_001_0	9			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								10.00	20.00	30.00					5.00	10.00	15.00													20.00						10.00				10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			20.00			10.00	10.00		10.00
H8578	001	0	1	01	01	H8578_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	90	1	2						90	30		31								45.00	90.00	135.00					40.00	80.00	120.00													90.00						80.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	001	0	1	01	01	H8578_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	90	1	2						90	30		31								95.00	190.00	285.00					90.00	180.00	270.00													285.00						270.00				95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	001	0	1	01	01	H8578_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												28							28																							28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	004	0	1	01	01	H8578_004_0	9			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	004	0	1	01	01	H8578_004_0	9			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								10.00	20.00	30.00					5.00	10.00	15.00													20.00						10.00				10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			20.00			10.00	10.00		10.00
H8578	004	0	1	01	01	H8578_004_0	9			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	90	1	2						90	30		31								45.00	90.00	135.00					40.00	80.00	120.00													90.00						80.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	004	0	1	01	01	H8578_004_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	90	1	2						90	30		31								95.00	190.00	285.00					90.00	180.00	270.00													285.00						270.00				95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	004	0	1	01	01	H8578_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	28						1.00	28																							28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	012	0	1	01	01	H8578_012_0	9			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	012	0	1	01	01	H8578_012_0	9			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								10.00	20.00	30.00					5.00	10.00	15.00													20.00						10.00				10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			20.00			10.00	10.00		10.00
H8578	012	0	1	01	01	H8578_012_0	9			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	90	1	2						90	30		31								45.00	90.00	135.00					40.00	80.00	120.00													90.00						80.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	012	0	1	01	01	H8578_012_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	90	1	2						90	30		31								95.00	190.00	285.00					90.00	180.00	270.00													285.00						270.00				95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	012	0	1	01	01	H8578_012_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	26						1.00	26																							26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	018	0	1	01	01	H8578_018_0	10			Preferred Generic	4	11	1	2	1	1		111	01		100	1				30	60	90	1	2						90	30		31								4.00	8.00	12.00					0.00	0.00	0.00													8.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8578	018	0	1	01	01	H8578_018_0	10			Generic	4	11	3	2	2	1		111	01		100	1				30	60	90	1	2						90	30		31								10.00	20.00	30.00					5.00	10.00	15.00													20.00						10.00				10.00				10.00			0.33	0.17				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	5.00	10.00	15.00			20.00			10.00	10.00		10.00
H8578	018	0	1	01	01	H8578_018_0	10			Preferred Brand	4	11	1	2	3	1		111	01		100	1				30	60	90	1	2						90	30		31								45.00	90.00	135.00					40.00	80.00	120.00													90.00						80.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	018	0	1	01	01	H8578_018_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01		100	1				30	60	90	1	2						90	30		31								95.00	190.00	285.00					90.00	180.00	270.00													285.00						270.00				95.00				95.00			3.17	3.00				3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			70.00			70.00	35.00		35.00
H8578	018	0	1	01	01	H8578_018_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	26						1.00	26																							26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	010	0	1	04	01	H8604_010_0	14			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					3.00	6.00	9.00											13.00	26.00	39.00				3.00	0.00	0.00				13.00				13.00			0.43	0.10		0.43	0.10	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	010	0	1	04	01	H8604_010_0	14			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	0.00	0.00	20.00		20.00
H8604	010	0	1	04	01	H8604_010_0	14			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	010	0	1	04	01	H8604_010_0	14			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	010	0	1	04	01	H8604_010_0	14			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	31						1000.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	011	0	1	04	01	H8604_011_0	14			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					3.00	6.00	9.00											13.00	26.00	39.00				3.00	0.00	0.00				13.00				13.00			0.43	0.10		0.43	0.10	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	011	0	1	04	01	H8604_011_0	14			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	0.00	0.00	20.00		20.00
H8604	011	0	1	04	01	H8604_011_0	14			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	011	0	1	04	01	H8604_011_0	14			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	011	0	1	04	01	H8604_011_0	14			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	31						1000.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	013	0	1	04	01	H8604_013_0	14			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					3.00	6.00	9.00											13.00	26.00	39.00				3.00	0.00	0.00				13.00				13.00			0.43	0.10		0.43	0.10	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	013	0	1	04	01	H8604_013_0	14			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	0.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	0.00	0.00	20.00		20.00
H8604	013	0	1	04	01	H8604_013_0	14			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	013	0	1	04	01	H8604_013_0	14			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	013	0	1	04	01	H8604_013_0	14			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	31						1000.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	014	1	1	04	01	H8604_014_1	17			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					0.00	0.00	0.00											13.00	26.00	39.00				0.00	0.00	0.00				0.00				0.00			0.43	0.00		0.43	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	014	1	1	04	01	H8604_014_1	17			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				0.00				0.00			0.67	0.00		0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H8604	014	1	1	04	01	H8604_014_1	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	014	1	1	04	01	H8604_014_1	17			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	014	1	1	04	01	H8604_014_1	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	33						1000.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	014	2	1	04	01	H8604_014_2	16			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					0.00	0.00	0.00											13.00	26.00	39.00				0.00	0.00	0.00				0.00				0.00			0.43	0.00		0.43	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8604	014	2	1	04	01	H8604_014_2	16			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					0.00	0.00	0.00											20.00	40.00	60.00				0.00	0.00	0.00				0.00				0.00			0.67	0.00		0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	0.00	0.00	0.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00
H8604	014	2	1	04	01	H8604_014_2	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	125.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	014	2	1	04	01	H8604_014_2	16			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	275.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8604	014	2	1	04	01	H8604_014_2	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1000.00	33						1000.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	003	0	1	04	01	H8634_003_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8634	003	0	1	04	01	H8634_003_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8634	003	0	1	04	01	H8634_003_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8634	003	0	1	04	01	H8634_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8634	003	0	1	04	01	H8634_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	003	0	1	04	01	H8634_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	004	0	1	04	01	H8634_004_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8634	004	0	1	04	01	H8634_004_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8634	004	0	1	04	01	H8634_004_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8634	004	0	1	04	01	H8634_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8634	004	0	1	04	01	H8634_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	004	0	1	04	01	H8634_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	008	0	1	04	01	H8634_008_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8634	008	0	1	04	01	H8634_008_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8634	008	0	1	04	01	H8634_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	008	0	1	04	01	H8634_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	008	0	1	04	01	H8634_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	010	0	1	04	01	H8634_010_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8634	010	0	1	04	01	H8634_010_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8634	010	0	1	04	01	H8634_010_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8634	010	0	1	04	01	H8634_010_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8634	010	0	1	04	01	H8634_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	010	0	1	04	01	H8634_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	012	0	1	04	01	H8634_012_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8634	012	0	1	04	01	H8634_012_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8634	012	0	1	04	01	H8634_012_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8634	012	0	1	04	01	H8634_012_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8634	012	0	1	04	01	H8634_012_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	012	0	1	04	01	H8634_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	014	0	1	04	01	H8634_014_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8634	014	0	1	04	01	H8634_014_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8634	014	0	1	04	01	H8634_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	014	0	1	04	01	H8634_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	014	0	1	04	01	H8634_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	015	0	1	04	01	H8634_015_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8634	015	0	1	04	01	H8634_015_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8634	015	0	1	04	01	H8634_015_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	015	0	1	04	01	H8634_015_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	015	0	1	04	01	H8634_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	016	0	1	04	01	H8634_016_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8634	016	0	1	04	01	H8634_016_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8634	016	0	1	04	01	H8634_016_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8634	016	0	1	04	01	H8634_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8634	016	0	1	04	01	H8634_016_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	016	0	1	04	01	H8634_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	017	0	1	04	01	H8634_017_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H8634	017	0	1	04	01	H8634_017_0	7			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8634	017	0	1	04	01	H8634_017_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H8634	017	0	1	04	01	H8634_017_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H8634	017	0	1	04	01	H8634_017_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	017	0	1	04	01	H8634_017_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	018	0	1	04	01	H8634_018_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8634	018	0	1	04	01	H8634_018_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8634	018	0	1	04	01	H8634_018_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	018	0	1	04	01	H8634_018_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	018	0	1	04	01	H8634_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	020	0	1	04	01	H8634_020_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8634	020	0	1	04	01	H8634_020_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8634	020	0	1	04	01	H8634_020_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	020	0	1	04	01	H8634_020_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	020	0	1	04	01	H8634_020_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8634	021	0	1	04	01	H8634_021_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H8634	021	0	1	04	01	H8634_021_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H8634	021	0	1	04	01	H8634_021_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	021	0	1	04	01	H8634_021_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8634	021	0	1	04	01	H8634_021_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	003	0	1	02	01	H8649_003_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	003	0	1	02	01	H8649_003_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8649	003	0	1	02	01	H8649_003_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	003	0	1	02	01	H8649_003_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8649	003	0	1	02	01	H8649_003_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											87.58	25	25	25				80.03	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8649	003	0	1	02	01	H8649_003_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											31.01	50	50	50				26.04	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	003	0	1	02	01	H8649_003_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											905.56	33						738.58	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8649	008	0	1	02	01	H8649_008_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	008	0	1	02	01	H8649_008_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8649	008	0	1	02	01	H8649_008_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	008	0	1	02	01	H8649_008_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8649	008	0	1	02	01	H8649_008_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											94.31	25	25	25				83.78	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8649	008	0	1	02	01	H8649_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											33.76	50	50	50				26.01	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8649	008	0	1	02	01	H8649_008_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											830.33	33						625.65	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H8711	004	0	1	04	01	H8711_004_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8711	004	0	1	04	01	H8711_004_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8711	004	0	1	04	01	H8711_004_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H8711	004	0	1	04	01	H8711_004_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											96.87	50	50	50				96.87	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8711	004	0	1	04	01	H8711_004_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H8711	004	0	1	04	01	H8711_004_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8764	001	0	1	01	01	H8764_001_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	4.00		8.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													4.00		8.00						8.00				4.00		4.00
H8764	001	0	1	01	01	H8764_001_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	4.00		8.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H8764	001	0	1	01	01	H8764_001_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													8.00		16.00						16.00				8.00		8.00
H8764	001	0	1	01	01	H8764_001_0	7			Generic	4	01	1	2	2	3	110		01	100		1	30		100				1	2			100				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H8764	001	0	1	01	01	H8764_001_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	45.00		90.00																					90.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	001	0	1	01	01	H8764_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	95.00		190.00																					190.00																95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	001	0	1	01	01	H8764_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00												35.00		35.00
H8764	001	0	1	01	01	H8764_001_0	7			Select Diabetic Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	11.00		22.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00		22.00						22.00				11.00		11.00
H8764	002	0	1	02	01	H8764_002_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													0.00		0.00						0.00				0.00		0.00
H8764	002	0	1	02	01	H8764_002_0	7			Preferred Generic	4	01	1	2	1	3	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H8764	002	0	1	02	01	H8764_002_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													10.00		20.00						20.00				10.00		10.00
H8764	002	0	1	02	01	H8764_002_0	7			Generic	4	01	1	2	2	3	110		01	100		1	30		100				1	2			100				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs										1																	
H8764	002	0	1	02	01	H8764_002_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	42.00		84.00																					84.00																42.00				42.00		1.40						1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	002	0	1	02	01	H8764_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	90.00		180.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	002	0	1	02	01	H8764_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00												35.00		35.00
H8764	002	0	1	02	01	H8764_002_0	7			Select Diabetic Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	11.00		22.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00		22.00						22.00				11.00		11.00
H8764	003	0	1	01	01	H8764_003_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	9.00		18.00																					18.00																9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													9.00		18.00						18.00				9.00		9.00
H8764	003	0	1	01	01	H8764_003_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	18.00		36.00																					36.00																18.00				18.00		0.60						0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													18.00		36.00						36.00				18.00		18.00
H8764	003	0	1	01	01	H8764_003_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	003	0	1	01	01	H8764_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	100.00		200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	003	0	1	01	01	H8764_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00												35.00		35.00
H8764	003	0	1	01	01	H8764_003_0	7			Select Diabetic Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	11.00		22.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00		22.00						22.00				11.00		11.00
H8764	004	0	1	01	01	H8764_004_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		31	9.00		18.00																					18.00																9.00				9.00		0.30						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													9.00		18.00						18.00				9.00		9.00
H8764	004	0	1	01	01	H8764_004_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		100				1	2			100				30		31	18.00		36.00																					36.00																18.00				18.00		0.60						0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													18.00		36.00						36.00				18.00		18.00
H8764	004	0	1	01	01	H8764_004_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		94.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	004	0	1	01	01	H8764_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	100.00		200.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00		70.00						70.00				35.00		35.00
H8764	004	0	1	01	01	H8764_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													35.00												35.00		35.00
H8764	004	0	1	01	01	H8764_004_0	7			Select Diabetic Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	11.00		22.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs													11.00		22.00						22.00				11.00		11.00
H8768	003	0	1	04	01	H8768_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	003	0	1	04	01	H8768_003_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	003	0	1	04	01	H8768_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	003	0	1	04	01	H8768_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	003	0	1	04	01	H8768_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	003	0	1	04	01	H8768_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	003	0	1	04	01	H8768_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				483.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	005	0	1	04	01	H8768_005_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	005	0	1	04	01	H8768_005_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	005	0	1	04	01	H8768_005_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	005	0	1	04	01	H8768_005_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	005	0	1	04	01	H8768_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	005	0	1	04	01	H8768_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	005	0	1	04	01	H8768_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	007	0	1	04	01	H8768_007_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	007	0	1	04	01	H8768_007_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	007	0	1	04	01	H8768_007_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	007	0	1	04	01	H8768_007_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	007	0	1	04	01	H8768_007_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	007	0	1	04	01	H8768_007_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	007	0	1	04	01	H8768_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				635.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	008	0	1	04	01	H8768_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	008	0	1	04	01	H8768_008_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	008	0	1	04	01	H8768_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	008	0	1	04	01	H8768_008_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	008	0	1	04	01	H8768_008_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	008	0	1	04	01	H8768_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	008	0	1	04	01	H8768_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				541.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	009	0	1	04	01	H8768_009_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	009	0	1	04	01	H8768_009_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	009	0	1	04	01	H8768_009_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	009	0	1	04	01	H8768_009_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	009	0	1	04	01	H8768_009_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	009	0	1	04	01	H8768_009_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	009	0	1	04	01	H8768_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				514.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	010	0	1	04	01	H8768_010_0	6			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	010	0	1	04	01	H8768_010_0	6			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	010	0	1	04	01	H8768_010_0	6			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	010	0	1	04	01	H8768_010_0	6			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	010	0	1	04	01	H8768_010_0	6			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H8768	010	0	1	04	01	H8768_010_0	6			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H8768	010	0	1	04	01	H8768_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											326.00	30						416.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	011	0	1	04	01	H8768_011_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	011	0	1	04	01	H8768_011_0	5			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		100	2	2						100	30		31								10.00		30.00					0.00		0.00													30.00						0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	011	0	1	04	01	H8768_011_0	5			Generic	4	01	3	2	2	1		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	011	0	1	04	01	H8768_011_0	5			Generic	4	01	3	2	2	3		110	01		100	1				30		100	2	2						100	30		31								20.00		60.00					0.00		0.00													60.00						0.00				20.00				20.00			0.66	0.00				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	011	0	1	04	01	H8768_011_0	5			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		100	2	2						100	30		31								47.00		141.00					47.00		131.00													141.00						131.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H8768	011	0	1	04	01	H8768_011_0	5			Non-Preferred Drug	4	11	1	2	4	1		110	01		100	1				30		100	2	2						100	30		31								100.00		300.00					100.00		290.00													300.00						290.00				100.00				100.00			3.33	3.33				3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		95.00			105.00			95.00	35.00		35.00
H8768	011	0	1	04	01	H8768_011_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											476.00	33						660.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	013	0	1	04	01	H8768_013_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	013	0	1	04	01	H8768_013_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	013	0	1	04	01	H8768_013_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	013	0	1	04	01	H8768_013_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	013	0	1	04	01	H8768_013_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	013	0	1	04	01	H8768_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	013	0	1	04	01	H8768_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	014	0	1	04	01	H8768_014_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	014	0	1	04	01	H8768_014_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	014	0	1	04	01	H8768_014_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	014	0	1	04	01	H8768_014_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	014	0	1	04	01	H8768_014_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	014	0	1	04	01	H8768_014_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	014	0	1	04	01	H8768_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				453.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	016	0	1	04	01	H8768_016_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	016	0	1	04	01	H8768_016_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	016	0	1	04	01	H8768_016_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	016	0	1	04	01	H8768_016_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	016	0	1	04	01	H8768_016_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	016	0	1	04	01	H8768_016_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	016	0	1	04	01	H8768_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				491.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	017	1	1	04	01	H8768_017_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	017	1	1	04	01	H8768_017_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	017	1	1	04	01	H8768_017_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	017	1	1	04	01	H8768_017_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	017	1	1	04	01	H8768_017_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	017	1	1	04	01	H8768_017_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	017	1	1	04	01	H8768_017_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				448.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	017	2	1	04	01	H8768_017_2	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	017	2	1	04	01	H8768_017_2	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	017	2	1	04	01	H8768_017_2	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	017	2	1	04	01	H8768_017_2	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	017	2	1	04	01	H8768_017_2	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	017	2	1	04	01	H8768_017_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	017	2	1	04	01	H8768_017_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				448.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	022	0	1	04	01	H8768_022_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	022	0	1	04	01	H8768_022_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	022	0	1	04	01	H8768_022_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	022	0	1	04	01	H8768_022_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	022	0	1	04	01	H8768_022_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	022	0	1	04	01	H8768_022_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	022	0	1	04	01	H8768_022_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				529.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	023	0	1	04	01	H8768_023_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	023	0	1	04	01	H8768_023_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	023	0	1	04	01	H8768_023_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	023	0	1	04	01	H8768_023_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		16.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	023	0	1	04	01	H8768_023_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	023	0	1	04	01	H8768_023_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	023	0	1	04	01	H8768_023_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				554.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	024	0	1	04	01	H8768_024_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	024	0	1	04	01	H8768_024_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	024	0	1	04	01	H8768_024_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	024	0	1	04	01	H8768_024_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	024	0	1	04	01	H8768_024_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	024	0	1	04	01	H8768_024_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	024	0	1	04	01	H8768_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				557.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	026	0	1	04	01	H8768_026_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	026	0	1	04	01	H8768_026_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	026	0	1	04	01	H8768_026_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	026	0	1	04	01	H8768_026_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	026	0	1	04	01	H8768_026_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	026	0	1	04	01	H8768_026_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	026	0	1	04	01	H8768_026_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				499.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	027	0	1	04	01	H8768_027_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	027	0	1	04	01	H8768_027_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	027	0	1	04	01	H8768_027_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	027	0	1	04	01	H8768_027_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	027	0	1	04	01	H8768_027_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	027	0	1	04	01	H8768_027_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	027	0	1	04	01	H8768_027_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				415.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	030	0	1	04	01	H8768_030_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	030	0	1	04	01	H8768_030_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	030	0	1	04	01	H8768_030_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	030	0	1	04	01	H8768_030_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	030	0	1	04	01	H8768_030_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	030	0	1	04	01	H8768_030_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	030	0	1	04	01	H8768_030_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				593.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	032	0	1	04	01	H8768_032_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	032	0	1	04	01	H8768_032_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	032	0	1	04	01	H8768_032_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	032	0	1	04	01	H8768_032_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	032	0	1	04	01	H8768_032_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	032	0	1	04	01	H8768_032_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	032	0	1	04	01	H8768_032_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				441.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	034	0	1	04	01	H8768_034_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	034	0	1	04	01	H8768_034_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	034	0	1	04	01	H8768_034_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	034	0	1	04	01	H8768_034_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	034	0	1	04	01	H8768_034_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	034	0	1	04	01	H8768_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	034	0	1	04	01	H8768_034_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				643.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	035	0	1	04	01	H8768_035_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	035	0	1	04	01	H8768_035_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	035	0	1	04	01	H8768_035_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	035	0	1	04	01	H8768_035_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	035	0	1	04	01	H8768_035_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	45.00		135.00																											135.00						125.00				45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	035	0	1	04	01	H8768_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	95.00		285.00																											285.00						275.00				95.00				95.00		3.16						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	035	0	1	04	01	H8768_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				246.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	037	1	1	04	01	H8768_037_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	037	1	1	04	01	H8768_037_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	037	1	1	04	01	H8768_037_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	037	1	1	04	01	H8768_037_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	037	1	1	04	01	H8768_037_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	037	1	1	04	01	H8768_037_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	037	1	1	04	01	H8768_037_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				386.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	037	2	1	04	01	H8768_037_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	037	2	1	04	01	H8768_037_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	037	2	1	04	01	H8768_037_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	037	2	1	04	01	H8768_037_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	037	2	1	04	01	H8768_037_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	037	2	1	04	01	H8768_037_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	037	2	1	04	01	H8768_037_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				386.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	038	1	1	04	01	H8768_038_1	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	038	1	1	04	01	H8768_038_1	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	038	1	1	04	01	H8768_038_1	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	038	1	1	04	01	H8768_038_1	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	038	1	1	04	01	H8768_038_1	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	038	1	1	04	01	H8768_038_1	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	038	1	1	04	01	H8768_038_1	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				654.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	038	2	1	04	01	H8768_038_2	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	038	2	1	04	01	H8768_038_2	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	038	2	1	04	01	H8768_038_2	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	038	2	1	04	01	H8768_038_2	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	038	2	1	04	01	H8768_038_2	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	038	2	1	04	01	H8768_038_2	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	038	2	1	04	01	H8768_038_2	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				654.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	039	0	1	04	01	H8768_039_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	039	0	1	04	01	H8768_039_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	039	0	1	04	01	H8768_039_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	039	0	1	04	01	H8768_039_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	039	0	1	04	01	H8768_039_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	039	0	1	04	01	H8768_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	039	0	1	04	01	H8768_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				553.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	040	0	1	04	01	H8768_040_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	040	0	1	04	01	H8768_040_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	040	0	1	04	01	H8768_040_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	040	0	1	04	01	H8768_040_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	040	0	1	04	01	H8768_040_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	040	0	1	04	01	H8768_040_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	040	0	1	04	01	H8768_040_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				343.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	042	0	1	04	01	H8768_042_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	042	0	1	04	01	H8768_042_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	042	0	1	04	01	H8768_042_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	042	0	1	04	01	H8768_042_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H8768	042	0	1	04	01	H8768_042_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	042	0	1	04	01	H8768_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	042	0	1	04	01	H8768_042_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				518.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	043	0	1	04	01	H8768_043_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	043	0	1	04	01	H8768_043_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	043	0	1	04	01	H8768_043_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	043	0	1	04	01	H8768_043_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	043	0	1	04	01	H8768_043_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	043	0	1	04	01	H8768_043_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	043	0	1	04	01	H8768_043_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				234.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	044	0	1	04	01	H8768_044_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	044	0	1	04	01	H8768_044_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	044	0	1	04	01	H8768_044_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	044	0	1	04	01	H8768_044_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	044	0	1	04	01	H8768_044_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	044	0	1	04	01	H8768_044_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	044	0	1	04	01	H8768_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				523.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	046	0	1	04	01	H8768_046_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	046	0	1	04	01	H8768_046_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	046	0	1	04	01	H8768_046_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	046	0	1	04	01	H8768_046_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	046	0	1	04	01	H8768_046_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	046	0	1	04	01	H8768_046_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	046	0	1	04	01	H8768_046_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				467.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	047	0	1	04	01	H8768_047_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	047	0	1	04	01	H8768_047_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	047	0	1	04	01	H8768_047_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	047	0	1	04	01	H8768_047_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	047	0	1	04	01	H8768_047_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	047	0	1	04	01	H8768_047_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	047	0	1	04	01	H8768_047_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				255.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	049	0	1	04	01	H8768_049_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	049	0	1	04	01	H8768_049_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	049	0	1	04	01	H8768_049_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	049	0	1	04	01	H8768_049_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	049	0	1	04	01	H8768_049_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	049	0	1	04	01	H8768_049_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	049	0	1	04	01	H8768_049_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				711.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	050	0	1	04	01	H8768_050_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	050	0	1	04	01	H8768_050_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	050	0	1	04	01	H8768_050_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	050	0	1	04	01	H8768_050_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	10.00		20.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	050	0	1	04	01	H8768_050_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	050	0	1	04	01	H8768_050_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	050	0	1	04	01	H8768_050_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				426.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	051	0	1	04	01	H8768_051_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	051	0	1	04	01	H8768_051_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8768	051	0	1	04	01	H8768_051_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8768	051	0	1	04	01	H8768_051_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	5.00		10.00																											15.00						0.00				5.00				5.00		0.16						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H8768	051	0	1	04	01	H8768_051_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	051	0	1	04	01	H8768_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
H8768	051	0	1	04	01	H8768_051_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				253.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	001	0	1	04	01	H8783_001_0	10			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	001	0	1	04	01	H8783_001_0	10			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	001	0	1	04	01	H8783_001_0	10			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8783	001	0	1	04	01	H8783_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	001	0	1	04	01	H8783_001_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				3083.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	002	0	1	04	01	H8783_002_0	9			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	002	0	1	04	01	H8783_002_0	9			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	002	0	1	04	01	H8783_002_0	9			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8783	002	0	1	04	01	H8783_002_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	002	0	1	04	01	H8783_002_0	9			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				2990.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	003	0	1	04	01	H8783_003_0	10			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	003	0	1	04	01	H8783_003_0	10			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	10.00	20.00	30.00																			10.00	20.00	20.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	003	0	1	04	01	H8783_003_0	10			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	47.00	94.00	141.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8783	003	0	1	04	01	H8783_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8783	003	0	1	04	01	H8783_003_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				1735.00	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8786	001	0	1	48	05	H8786_001_0	7			Generic Drugs	4	11		2	1	1	111		10	111		1	31	62	93				2	2	31	62	93					10	34																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H8786	001	0	1	48	05	H8786_001_0	7			Brand Drugs	4	11			2	1	111		10	111		1	31	62	93				2	2	31	62	93					10	34																																																					Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	1	0.00	11.20			0.00	11.20	0.00	11.20																		
H8786	001	0	1	48	05	H8786_001_0	7			Non-Medicare Rx Drugs	4	11		2	3	1	010		10	000		1	31															10	34																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	2	0.00	0.00	0.00	0.00			0.00	0.00																		
H8786	001	0	1	48	05	H8786_001_0	7			Non-Medicare OTC Drugs	4	11		2	4	1	010		10	000		1	31															10	34																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx Drugs, Non-Medicare OTC Drugs	2	0.00	0.00	0.00	0.00			0.00	0.00																		
H8797	003	0	1	02	01	H8797_003_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	003	0	1	02	01	H8797_003_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	003	0	1	02	01	H8797_003_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8797	003	0	1	02	01	H8797_003_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	003	0	1	02	01	H8797_003_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	004	0	1	02	01	H8797_004_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	004	0	1	02	01	H8797_004_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	004	0	1	02	01	H8797_004_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8797	004	0	1	02	01	H8797_004_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8797	004	0	1	02	01	H8797_004_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8845	002	0	1	01	01	H8845_002_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8845	002	0	1	01	01	H8845_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8845	002	0	1	01	01	H8845_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H8845	002	0	1	01	01	H8845_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8845	002	0	1	01	01	H8845_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1144.10	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H8845	002	0	1	01	01	H8845_002_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	001	0	1	01	01	H8849_001_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	001	0	1	01	01	H8849_001_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	001	0	1	01	01	H8849_001_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	001	0	1	01	01	H8849_001_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	001	0	1	01	01	H8849_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	001	0	1	01	01	H8849_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	001	0	1	01	01	H8849_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	001	0	1	01	01	H8849_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H8849	001	0	1	01	01	H8849_001_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	002	0	1	01	01	H8849_002_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	002	0	1	01	01	H8849_002_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	002	0	1	01	01	H8849_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	002	0	1	01	01	H8849_002_0	7			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		34	7.50	15.00	22.50																			0.00	0.00	0.00																7.50				7.50		0.25			0.00			0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	002	0	1	01	01	H8849_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8849	002	0	1	01	01	H8849_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.50	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H8849	002	0	1	01	01	H8849_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	002	0	1	01	01	H8849_002_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H8849	002	0	1	01	01	H8849_002_0	7			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	003	0	1	01	01	H8849_003_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	003	0	1	01	01	H8849_003_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	003	0	1	01	01	H8849_003_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	003	0	1	01	01	H8849_003_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	003	0	1	01	01	H8849_003_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	003	0	1	01	01	H8849_003_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	003	0	1	01	01	H8849_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	003	0	1	01	01	H8849_003_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H8849	003	0	1	01	01	H8849_003_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	005	0	1	01	01	H8849_005_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	005	0	1	01	01	H8849_005_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	005	0	1	01	01	H8849_005_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	005	0	1	01	01	H8849_005_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	005	0	1	01	01	H8849_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	005	0	1	01	01	H8849_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	005	0	1	01	01	H8849_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	005	0	1	01	01	H8849_005_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H8849	005	0	1	01	01	H8849_005_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	006	0	1	01	01	H8849_006_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	006	0	1	01	01	H8849_006_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	006	0	1	01	01	H8849_006_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	006	0	1	01	01	H8849_006_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	006	0	1	01	01	H8849_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	006	0	1	01	01	H8849_006_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	006	0	1	01	01	H8849_006_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	009	0	1	01	01	H8849_009_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	009	0	1	01	01	H8849_009_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	009	0	1	01	01	H8849_009_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	009	0	1	01	01	H8849_009_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	009	0	1	01	01	H8849_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	009	0	1	01	01	H8849_009_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	009	0	1	01	01	H8849_009_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	013	0	1	01	01	H8849_013_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	013	0	1	01	01	H8849_013_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	013	0	1	01	01	H8849_013_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	013	0	1	01	01	H8849_013_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8849	013	0	1	01	01	H8849_013_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	013	0	1	01	01	H8849_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8849	013	0	1	01	01	H8849_013_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8849	013	0	1	01	01	H8849_013_0	7			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H8849	013	0	1	01	01	H8849_013_0	7			Select Care Drugs	4	11	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8889	001	0	1	04	01	H8889_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	001	0	1	04	01	H8889_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		10.00
H8889	001	0	1	04	01	H8889_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	001	0	1	04	01	H8889_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.28	50	50	50				94.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	001	0	1	04	01	H8889_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	002	0	1	04	01	H8889_002_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	002	0	1	04	01	H8889_002_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		10.00
H8889	002	0	1	04	01	H8889_002_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	002	0	1	04	01	H8889_002_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											83.67	46	46	46				106.28	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	002	0	1	04	01	H8889_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	003	0	1	04	01	H8889_003_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	003	0	1	04	01	H8889_003_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	0.00				20.00				8.00			0.67	0.27		0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	0.00	20.00		8.00
H8889	003	0	1	04	01	H8889_003_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	003	0	1	04	01	H8889_003_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.96	50	50	50				48.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	003	0	1	04	01	H8889_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	004	0	1	04	01	H8889_004_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	004	0	1	04	01	H8889_004_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				10.00			0.67	0.33		0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		10.00
H8889	004	0	1	04	01	H8889_004_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	004	0	1	04	01	H8889_004_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.63	50	50	50				74.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	004	0	1	04	01	H8889_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	005	0	1	04	01	H8889_005_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				0.00			0.33	0.00		0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	005	0	1	04	01	H8889_005_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					14.00	28.00	42.00											20.00	40.00	60.00				14.00	28.00	0.00				20.00				14.00			0.67	0.47		0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	14.00	28.00	42.00	20.00	40.00	60.00	14.00	28.00	0.00	20.00		14.00
H8889	005	0	1	04	01	H8889_005_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	005	0	1	04	01	H8889_005_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											68.93	50	50	50				76.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	005	0	1	04	01	H8889_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	008	0	1	04	01	H8889_008_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				0.00			0.50	0.00		0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	008	0	1	04	01	H8889_008_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					14.00	28.00	42.00											20.00	40.00	60.00				14.00	28.00	0.00				20.00				14.00			0.67	0.47		0.67	0.47	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	14.00	28.00	42.00	20.00	40.00	60.00	14.00	28.00	0.00	20.00		14.00
H8889	008	0	1	04	01	H8889_008_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	131.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	008	0	1	04	01	H8889_008_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											76.19	50	50	50				80.14	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H8889	008	0	1	04	01	H8889_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	010	0	1	04	01	H8889_010_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	010	0	1	04	01	H8889_010_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	0.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00				14.00	28.00	0.00				14.00		14.00
H8889	010	0	1	04	01	H8889_010_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	010	0	1	04	01	H8889_010_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				42.81	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	010	0	1	04	01	H8889_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	011	0	1	04	01	H8889_011_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	011	0	1	04	01	H8889_011_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	0.00				10.00		10.00
H8889	011	0	1	04	01	H8889_011_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	011	0	1	04	01	H8889_011_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				43.64	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	011	0	1	04	01	H8889_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	012	0	1	04	01	H8889_012_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	012	0	1	04	01	H8889_012_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	0.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00				12.00	24.00	0.00				12.00		12.00
H8889	012	0	1	04	01	H8889_012_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	012	0	1	04	01	H8889_012_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.28	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	012	0	1	04	01	H8889_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	013	0	1	04	01	H8889_013_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	013	0	1	04	01	H8889_013_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	0.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	0.00				10.00		10.00
H8889	013	0	1	04	01	H8889_013_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	013	0	1	04	01	H8889_013_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				43.80	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	013	0	1	04	01	H8889_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	014	0	1	04	01	H8889_014_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	014	0	1	04	01	H8889_014_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	14.00	28.00	42.00																			14.00	28.00	0.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00	28.00	42.00				14.00	28.00	0.00				14.00		14.00
H8889	014	0	1	04	01	H8889_014_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	014	0	1	04	01	H8889_014_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				80.42	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	014	0	1	04	01	H8889_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	015	0	1	04	01	H8889_015_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8889	015	0	1	04	01	H8889_015_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	12.00	24.00	36.00																			12.00	24.00	0.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00				12.00	24.00	0.00				12.00		12.00
H8889	015	0	1	04	01	H8889_015_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	131.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	015	0	1	04	01	H8889_015_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				47.70	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H8889	015	0	1	04	01	H8889_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H8902	001	0	1	01	01	H8902_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	001	0	1	01	01	H8902_001_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H8902	001	0	1	01	01	H8902_001_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	001	0	1	01	01	H8902_001_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	001	0	1	01	01	H8902_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								40.00	80.00	100.00					35.00	70.00	85.00											40.00	80.00	100.00				35.00	70.00	85.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H8902	001	0	1	01	01	H8902_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	001	0	1	01	01	H8902_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	001	0	1	01	01	H8902_001_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	002	0	1	01	01	H8902_002_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	002	0	1	01	01	H8902_002_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	002	0	1	01	01	H8902_002_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	002	0	1	01	01	H8902_002_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	002	0	1	01	01	H8902_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								40.00	80.00	100.00					35.00	70.00	85.00											40.00	80.00	100.00				35.00	70.00	85.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H8902	002	0	1	01	01	H8902_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	002	0	1	01	01	H8902_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	002	0	1	01	01	H8902_002_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	003	0	1	01	01	H8902_003_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	003	0	1	01	01	H8902_003_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	003	0	1	01	01	H8902_003_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	003	0	1	01	01	H8902_003_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	003	0	1	01	01	H8902_003_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								40.00	80.00	100.00					35.00	70.00	85.00											40.00	80.00	100.00				35.00	70.00	85.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H8902	003	0	1	01	01	H8902_003_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	003	0	1	01	01	H8902_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	003	0	1	01	01	H8902_003_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	004	0	1	01	01	H8902_004_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	004	0	1	01	01	H8902_004_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H8902	004	0	1	01	01	H8902_004_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	004	0	1	01	01	H8902_004_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	004	0	1	01	01	H8902_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H8902	004	0	1	01	01	H8902_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	004	0	1	01	01	H8902_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	004	0	1	01	01	H8902_004_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	005	0	1	01	01	H8902_005_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	005	0	1	01	01	H8902_005_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H8902	005	0	1	01	01	H8902_005_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	005	0	1	01	01	H8902_005_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	005	0	1	01	01	H8902_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								40.00	80.00	100.00					35.00	70.00	85.00											40.00	80.00	100.00				35.00	70.00	85.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H8902	005	0	1	01	01	H8902_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	005	0	1	01	01	H8902_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	005	0	1	01	01	H8902_005_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	006	0	1	01	01	H8902_006_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	006	0	1	01	01	H8902_006_0	6			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	006	0	1	01	01	H8902_006_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	006	0	1	01	01	H8902_006_0	6			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	006	0	1	01	01	H8902_006_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								40.00	80.00	100.00					35.00	70.00	85.00											40.00	80.00	100.00				35.00	70.00	85.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
H8902	006	0	1	01	01	H8902_006_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	006	0	1	01	01	H8902_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	006	0	1	01	01	H8902_006_0	6			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	007	0	1	01	01	H8902_007_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	007	0	1	01	01	H8902_007_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	007	0	1	01	01	H8902_007_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	007	0	1	01	01	H8902_007_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	007	0	1	01	01	H8902_007_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								40.00	80.00	100.00					35.00	70.00	85.00											40.00	80.00	100.00				35.00	70.00	85.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H8902	007	0	1	01	01	H8902_007_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					90.00	180.00	250.00											100.00	200.00	280.00				90.00	180.00	250.00				100.00				100.00			3.33	3.00		3.33	3.00	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	007	0	1	01	01	H8902_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	007	0	1	01	01	H8902_007_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	008	0	1	01	01	H8902_008_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	008	0	1	01	01	H8902_008_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H8902	008	0	1	01	01	H8902_008_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	008	0	1	01	01	H8902_008_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H8902	008	0	1	01	01	H8902_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	121.00					40.00	80.00	100.00											47.00	94.00	121.00				40.00	80.00	100.00				47.00				47.00			1.57	1.33		1.57	1.33	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H8902	008	0	1	01	01	H8902_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	280.00					95.00	190.00	265.00											100.00	200.00	280.00				95.00	190.00	265.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	008	0	1	01	01	H8902_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8902	008	0	1	01	01	H8902_008_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8908	001	0	1	02	01	H8908_001_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H8908	001	0	1	02	01	H8908_001_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8908	001	0	1	02	01	H8908_001_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
H8908	001	0	1	02	01	H8908_001_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8908	001	0	1	02	01	H8908_001_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8908	001	0	1	02	01	H8908_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8908	001	0	1	02	01	H8908_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8908	002	0	1	01	01	H8908_002_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
H8908	002	0	1	01	01	H8908_002_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
H8908	002	0	1	01	01	H8908_002_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8908	002	0	1	01	01	H8908_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8908	002	0	1	01	01	H8908_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8908	004	0	1	02	01	H8908_004_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
H8908	004	0	1	02	01	H8908_004_0	7			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8908	004	0	1	02	01	H8908_004_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00
H8908	004	0	1	02	01	H8908_004_0	7			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									20.00		60.00				0.00		0.00				0.00				0.00		0.00				0.67	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8908	004	0	1	02	01	H8908_004_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8908	004	0	1	02	01	H8908_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
H8908	004	0	1	02	01	H8908_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
H8947	001	1	1	04	01	H8947_001_1	7			Preferred Generic	4	11	1	2	1	1		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	1	1	04	01	H8947_001_1	7			Preferred Generic	4	11	1	2	1	3		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	001	1	1	04	01	H8947_001_1	7			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	1	1	04	01	H8947_001_1	7			Generic	4	11	1	2	2	3		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	001	1	1	04	01	H8947_001_1	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					42.00		126.00					42.00		126.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00
H8947	001	1	1	04	01	H8947_001_1	7			Non-Preferred Brand	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					95.00		285.00					95.00		285.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	1	1	04	01	H8947_001_1	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2100.18	33						2100.18	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	2	1	04	01	H8947_001_2	6			Preferred Generic	4	11	1	2	1	1		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	2	1	04	01	H8947_001_2	6			Preferred Generic	4	11	1	2	1	3		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	001	2	1	04	01	H8947_001_2	6			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	2	1	04	01	H8947_001_2	6			Generic	4	11	1	2	2	3		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	001	2	1	04	01	H8947_001_2	6			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					42.00		126.00					42.00		126.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00
H8947	001	2	1	04	01	H8947_001_2	6			Non-Preferred Brand	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					95.00		285.00					95.00		285.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	001	2	1	04	01	H8947_001_2	6			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2100.18	33						2100.18	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	1	1	04	01	H8947_002_1	7			Preferred Generic	4	11	1	2	1	1		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	1	1	04	01	H8947_002_1	7			Preferred Generic	4	11	1	2	1	3		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	002	1	1	04	01	H8947_002_1	7			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	1	1	04	01	H8947_002_1	7			Generic	4	11	1	2	2	3		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	002	1	1	04	01	H8947_002_1	7			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					42.00		126.00					42.00		126.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00
H8947	002	1	1	04	01	H8947_002_1	7			Non-Preferred Brand	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					95.00		285.00					95.00		285.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	1	1	04	01	H8947_002_1	7			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2100.18	33						2100.18	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	2	1	04	01	H8947_002_2	6			Preferred Generic	4	11	1	2	1	1		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	2	1	04	01	H8947_002_2	6			Preferred Generic	4	11	1	2	1	3		110	01	110		1				30		90	1	2	30		90				30		31								15.00		45.00					0.00		0.00					0.00		0.00																15.00				15.00			0.50	0.00	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	002	2	1	04	01	H8947_002_2	6			Generic	4	11	1	2	2	1		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	2	1	04	01	H8947_002_2	6			Generic	4	11	1	2	2	3		110	01	110		1				30		90	1	2	30		90				30		31								20.00		60.00					0.00		0.00					0.00		0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H8947	002	2	1	04	01	H8947_002_2	6			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					42.00		126.00					42.00		126.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00
H8947	002	2	1	04	01	H8947_002_2	6			Non-Preferred Brand	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					95.00		285.00					95.00		285.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8947	002	2	1	04	01	H8947_002_2	6			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											2100.18	33						2100.18	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H8967	002	0	1	01	01	H8967_002_0	8			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	4.00	8.00	12.00																																						4.00			4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8967	002	0	1	01	01	H8967_002_0	8			Generic	4	01	1	2	2	1	111		10			1	30	60	90				2	2								10	31	10.00	20.00	30.00																																						10.00			10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8967	002	0	1	01	01	H8967_002_0	8			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				2	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00										35.00		35.00
H8967	002	0	1	01	01	H8967_002_0	8			Non-Preferred Drug	4	10	1	2	4	1	111		10			1	30	60	90				2	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00										35.00		35.00
H8967	002	0	1	01	01	H8967_002_0	8			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31					33	33	33																																				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8967	002	0	1	01	01	H8967_002_0	8			Select Care Drugs	4	11	1	2	6	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H8998	001	0	1	04	01	H8998_001_0	8			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00
H8998	001	0	1	04	01	H8998_001_0	8			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H8998	001	0	1	04	01	H8998_001_0	8			Generic	4	11	3	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					5.00	10.00	15.00					0.00	0.00	0.00																20.00				20.00			0.67	0.17	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	0.00	0.00	0.00				20.00		20.00
H8998	001	0	1	04	01	H8998_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8998	001	0	1	04	01	H8998_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H8998	001	0	1	04	01	H8998_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											950.00	33						950.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
H9001	030	15	1	01	01	H9001_030_15	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	15	1	01	01	H9001_030_15	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	030	15	1	01	01	H9001_030_15	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	030	15	1	01	01	H9001_030_15	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	030	15	1	01	01	H9001_030_15	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	15	1	01	01	H9001_030_15	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	16	1	01	01	H9001_030_16	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	16	1	01	01	H9001_030_16	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	030	16	1	01	01	H9001_030_16	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	030	16	1	01	01	H9001_030_16	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	030	16	1	01	01	H9001_030_16	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	16	1	01	01	H9001_030_16	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	18	1	01	01	H9001_030_18	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	18	1	01	01	H9001_030_18	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	030	18	1	01	01	H9001_030_18	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	030	18	1	01	01	H9001_030_18	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	030	18	1	01	01	H9001_030_18	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	030	18	1	01	01	H9001_030_18	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	15	1	01	01	H9001_031_15	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	15	1	01	01	H9001_031_15	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	031	15	1	01	01	H9001_031_15	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	031	15	1	01	01	H9001_031_15	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	031	15	1	01	01	H9001_031_15	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	15	1	01	01	H9001_031_15	7			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	16	1	01	01	H9001_031_16	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	16	1	01	01	H9001_031_16	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	031	16	1	01	01	H9001_031_16	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	031	16	1	01	01	H9001_031_16	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	031	16	1	01	01	H9001_031_16	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	16	1	01	01	H9001_031_16	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	18	1	01	01	H9001_031_18	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	18	1	01	01	H9001_031_18	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	031	18	1	01	01	H9001_031_18	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	031	18	1	01	01	H9001_031_18	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	031	18	1	01	01	H9001_031_18	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	031	18	1	01	01	H9001_031_18	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	035	0	1	01	01	H9001_035_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	035	0	1	01	01	H9001_035_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	035	0	1	01	01	H9001_035_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	035	0	1	01	01	H9001_035_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	035	0	1	01	01	H9001_035_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	035	0	1	01	01	H9001_035_0	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	036	0	1	01	01	H9001_036_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	036	0	1	01	01	H9001_036_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	036	0	1	01	01	H9001_036_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	036	0	1	01	01	H9001_036_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	036	0	1	01	01	H9001_036_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	036	0	1	01	01	H9001_036_0	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	038	0	1	01	01	H9001_038_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	038	0	1	01	01	H9001_038_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													7.00	14.00	21.00				7.00	14.00	14.00				7.00		7.00
H9001	038	0	1	01	01	H9001_038_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	038	0	1	01	01	H9001_038_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	86.00	172.00	258.00																			86.00	172.00	172.00																86.00				86.00		2.87			2.87			2.77	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	038	0	1	01	01	H9001_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	038	0	1	01	01	H9001_038_0	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	040	0	1	01	01	H9001_040_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	040	0	1	01	01	H9001_040_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	9.00	18.00	27.00																			9.00	18.00	18.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													9.00	18.00	27.00				9.00	18.00	18.00				9.00		9.00
H9001	040	0	1	01	01	H9001_040_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	42.00	84.00	126.00																			42.00	84.00	84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	040	0	1	01	01	H9001_040_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9001	040	0	1	01	01	H9001_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9001	040	0	1	01	01	H9001_040_0	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9003	001	0	1	02	01	H9003_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9003	001	0	1	02	01	H9003_001_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	001	0	1	02	01	H9003_001_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H9003	001	0	1	02	01	H9003_001_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	001	0	1	02	01	H9003_001_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00
H9003	001	0	1	02	01	H9003_001_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9003	001	0	1	02	01	H9003_001_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9003	001	0	1	02	01	H9003_001_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9003	001	0	1	02	01	H9003_001_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	006	0	1	02	01	H9003_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9003	006	0	1	02	01	H9003_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	006	0	1	02	01	H9003_006_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H9003	006	0	1	02	01	H9003_006_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	006	0	1	02	01	H9003_006_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00
H9003	006	0	1	02	01	H9003_006_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9003	006	0	1	02	01	H9003_006_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9003	006	0	1	02	01	H9003_006_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9003	006	0	1	02	01	H9003_006_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	008	0	1	02	01	H9003_008_0	11			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								19.00	38.00	57.00					0.00	0.00	0.00					0.00	0.00	0.00																19.00				19.00			0.63	0.00	0.00			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00				19.00		19.00
H9003	008	0	1	02	01	H9003_008_0	11			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								19.00	38.00	57.00					0.00	0.00	0.00					0.00	0.00	0.00																19.00				19.00			0.63	0.00	0.00			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	008	0	1	02	01	H9003_008_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					10.00	20.00	20.00																20.00				20.00			0.66	0.33	0.33			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													20.00	40.00	60.00	10.00	20.00	30.00	10.00	20.00	20.00				20.00		20.00
H9003	008	0	1	02	01	H9003_008_0	11			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					10.00	20.00	30.00					10.00	20.00	20.00																20.00				20.00			0.66	0.33	0.33			0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	008	0	1	02	01	H9003_008_0	11			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	80.00																47.00				47.00			1.56	1.33	1.33			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	80.00				35.00		35.00
H9003	008	0	1	02	01	H9003_008_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					93.00	186.00	279.00					93.00	186.00	186.00																100.00				100.00			3.33	3.10	3.10			3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9003	008	0	1	02	01	H9003_008_0	11			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												29	29	29					29	29	29				29	29	29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9003	008	0	1	02	01	H9003_008_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	1		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9003	008	0	1	02	01	H9003_008_0	11			Vaccines ($0 cost sharing)	4	10	1	2	6	3		010	01	000		1				30											30		31								0.00							0.00																									0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	009	0	1	02	01	H9003_009_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9003	009	0	1	02	01	H9003_009_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	009	0	1	02	01	H9003_009_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													10.00	20.00	30.00				10.00	20.00	20.00				10.00		10.00
H9003	009	0	1	02	01	H9003_009_0	10			Generic	4	11	1	2	2	3	111		01	111		1	30	60	90				2	2	30	60	90				30		31	10.00	20.00	30.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9003	009	0	1	02	01	H9003_009_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00
H9003	009	0	1	02	01	H9003_009_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	90.00	180.00	270.00																			90.00	180.00	180.00																90.00				90.00		3.00			3.00			2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9003	009	0	1	02	01	H9003_009_0	10			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9003	009	0	1	02	01	H9003_009_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9003	009	0	1	02	01	H9003_009_0	10			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9042	002	1	1	04	01	H9042_002_1	7			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								6.00	12.00	18.00					0.00	0.00	0.00					2.00	4.00	0.00																	6.00			6.00			0.20	0.00	0.07			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													6.00	12.00	18.00	0.00	0.00	0.00	2.00	4.00	0.00				6.00		6.00
H9042	002	1	1	04	01	H9042_002_1	7			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								15.00	30.00	45.00					5.00	10.00	15.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.17	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	5.00	10.00	15.00	8.00	16.00	0.00				15.00		15.00
H9042	002	1	1	04	01	H9042_002_1	7			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9042	002	1	1	04	01	H9042_002_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								100.00	200.00	300.00					90.00	180.00	270.00					100.00	200.00	300.00																	100.00			100.00			3.33	3.00	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9042	002	1	1	04	01	H9042_002_1	7			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00									35.00		35.00
H9042	002	1	1	04	01	H9042_002_1	7			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H9042	002	2	1	04	01	H9042_002_2	7			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								6.00	12.00	18.00					0.00	0.00	0.00					2.00	4.00	0.00																	6.00			6.00			0.20	0.00	0.07			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													6.00	12.00	18.00	0.00	0.00	0.00	2.00	4.00	0.00				6.00		6.00
H9042	002	2	1	04	01	H9042_002_2	7			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								15.00	30.00	45.00					5.00	10.00	15.00					8.00	16.00	0.00																	15.00			15.00			0.50	0.17	0.27			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													15.00	30.00	45.00	5.00	10.00	15.00	8.00	16.00	0.00				15.00		15.00
H9042	002	2	1	04	01	H9042_002_2	7			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					37.00	74.00	111.00					47.00	94.00	141.00																	47.00			47.00			1.57	1.23	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9042	002	2	1	04	01	H9042_002_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								100.00	200.00	300.00					90.00	180.00	270.00					100.00	200.00	300.00																	100.00			100.00			3.33	3.00	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9042	002	2	1	04	01	H9042_002_2	7			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												33							33																								33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00									35.00		35.00
H9042	002	2	1	04	01	H9042_002_2	7			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00
H9047	013	0	2	01	01	H9047_013_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					1.00	2.00	2.40					1.00	2.00	2.40																12.00				12.00			0.40	0.03	0.03			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	013	0	2	01	01	H9047_013_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					1.00	2.00	2.40					1.00	2.00	2.40																12.00				12.00			0.40	0.03	0.03			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	013	0	2	01	01	H9047_013_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					12.00	19.20	28.80					12.00	19.20	28.80																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	013	0	2	01	01	H9047_013_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					47.00	94.00	112.80					47.00	94.00	112.80																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	013	0	2	01	01	H9047_013_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	216.00					90.00	180.00	216.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	013	0	2	01	01	H9047_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											684.78	33						1307.71	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	037	0	1	01	01	H9047_037_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	037	0	1	01	01	H9047_037_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	037	0	1	01	01	H9047_037_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	037	0	1	01	01	H9047_037_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	037	0	1	01	01	H9047_037_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	111.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	037	0	1	01	01	H9047_037_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	037	0	1	01	01	H9047_037_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											674.75	33						1294.79	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	054	0	1	01	01	H9047_054_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	054	0	1	01	01	H9047_054_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	054	0	1	01	01	H9047_054_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	054	0	1	01	01	H9047_054_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	054	0	1	01	01	H9047_054_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	111.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	054	0	1	01	01	H9047_054_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	054	0	1	01	01	H9047_054_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											896.81	33						1333.63	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	059	0	1	02	01	H9047_059_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	059	0	1	02	01	H9047_059_0	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	059	0	1	02	01	H9047_059_0	10			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	059	0	1	02	01	H9047_059_0	10			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	059	0	1	02	01	H9047_059_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	111.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	059	0	1	02	01	H9047_059_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	059	0	1	02	01	H9047_059_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											544.28	33						1419.39	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	062	0	1	02	01	H9047_062_0	11			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	062	0	1	02	01	H9047_062_0	11			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	062	0	1	02	01	H9047_062_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	062	0	1	02	01	H9047_062_0	11			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	062	0	1	02	01	H9047_062_0	11			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	111.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	062	0	1	02	01	H9047_062_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	062	0	1	02	01	H9047_062_0	11			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1619.30	33						1367.69	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	063	0	1	01	01	H9047_063_0	11			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	063	0	1	01	01	H9047_063_0	11			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	063	0	1	01	01	H9047_063_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	063	0	1	01	01	H9047_063_0	11			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	063	0	1	01	01	H9047_063_0	11			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	111.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	063	0	1	01	01	H9047_063_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	063	0	1	01	01	H9047_063_0	11			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1353.62	33						1093.02	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	064	0	1	01	01	H9047_064_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					0.00	0.00	0.00					0.00	0.00	0.00																12.00				12.00			0.40	0.00	0.00			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	064	0	1	01	01	H9047_064_0	8			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					0.00	0.00	0.00					0.00	0.00	0.00																12.00				12.00			0.40	0.00	0.00			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	064	0	1	01	01	H9047_064_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	064	0	1	01	01	H9047_064_0	8			Generic	4	11	1	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	064	0	1	01	01	H9047_064_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	74.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	064	0	1	01	01	H9047_064_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	180.00					90.00	180.00	180.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	064	0	1	01	01	H9047_064_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											596.11	33						1156.89	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	065	0	1	02	01	H9047_065_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				14.00			0.47	0.00	0.00			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	065	0	1	02	01	H9047_065_0	10			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				14.00			0.47	0.00	0.00			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	065	0	1	02	01	H9047_065_0	10			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	065	0	1	02	01	H9047_065_0	10			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	10.00	10.00					10.00	10.00	10.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H9047	065	0	1	02	01	H9047_065_0	10			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	88.80					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	065	0	1	02	01	H9047_065_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	240.00					100.00	200.00	240.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	065	0	1	02	01	H9047_065_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											953.60	33						1458.02	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	066	0	1	01	01	H9047_066_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	066	0	1	01	01	H9047_066_0	5			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9047	066	0	1	01	01	H9047_066_0	5			Generic	4	11	3	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9047	066	0	1	01	01	H9047_066_0	5			Generic	4	11	3	2	2	3		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					0.00	0.00	0.00					0.00	0.00	0.00																20.00				20.00			0.67	0.00	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H9047	066	0	1	01	01	H9047_066_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								37.00	74.00	111.00					37.00	74.00	74.00					37.00	74.00	74.00																37.00				37.00			1.23	1.23	1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	066	0	1	01	01	H9047_066_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	35.00	35.00	35.00	35.00	35.00				35.00		35.00
H9047	066	0	1	01	01	H9047_066_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											709.43	33						1320.06	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9065	002	0	1	02	01	H9065_002_0	9			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	002	0	1	02	01	H9065_002_0	9			Preferred Generic	4	01	3	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H9065	002	0	1	02	01	H9065_002_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					5.00	10.00	15.00					0.00	0.00	0.00																10.00				10.00			0.33	0.17	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	002	0	1	02	01	H9065_002_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H9065	002	0	1	02	01	H9065_002_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	002	0	1	02	01	H9065_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	002	0	1	02	01	H9065_002_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	002	0	1	02	01	H9065_002_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	003	0	1	02	01	H9065_003_0	9			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	003	0	1	02	01	H9065_003_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	003	0	1	02	01	H9065_003_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H9065	003	0	1	02	01	H9065_003_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	003	0	1	02	01	H9065_003_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	003	0	1	02	01	H9065_003_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	003	0	1	02	01	H9065_003_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	004	0	1	02	01	H9065_004_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	004	0	1	02	01	H9065_004_0	9			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	004	0	1	02	01	H9065_004_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	004	0	1	02	01	H9065_004_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	74.00	74.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H9065	004	0	1	02	01	H9065_004_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	004	0	1	02	01	H9065_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	004	0	1	02	01	H9065_004_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	004	0	1	02	01	H9065_004_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	006	0	1	01	01	H9065_006_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	006	0	1	01	01	H9065_006_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	006	0	1	01	01	H9065_006_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								16.00	32.00	48.00					16.00	32.00	48.00					0.00	0.00	0.00																16.00				16.00			0.53	0.53	0.00			0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	006	0	1	01	01	H9065_006_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9065	006	0	1	01	01	H9065_006_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	006	0	1	01	01	H9065_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	006	0	1	01	01	H9065_006_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	006	0	1	01	01	H9065_006_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	007	0	1	01	01	H9065_007_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	007	0	1	01	01	H9065_007_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	007	0	1	01	01	H9065_007_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								16.00	32.00	48.00					16.00	32.00	48.00					0.00	0.00	0.00																16.00				16.00			0.53	0.53	0.00			0.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	007	0	1	01	01	H9065_007_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	141.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9065	007	0	1	01	01	H9065_007_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	285.00	285.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	007	0	1	01	01	H9065_007_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	007	0	1	01	01	H9065_007_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	007	0	1	01	01	H9065_007_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9065	008	0	1	01	01	H9065_008_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								9.00	18.00	27.00					4.00	8.00	12.00					0.00	0.00	0.00																9.00				9.00			0.30	0.13	0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	008	0	1	01	01	H9065_008_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	008	0	1	01	01	H9065_008_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H9065	008	0	1	01	01	H9065_008_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	008	0	1	01	01	H9065_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	008	0	1	01	01	H9065_008_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9065	008	0	1	01	01	H9065_008_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9096	001	0	1	02	01	H9096_001_0	6			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	001	0	1	02	01	H9096_001_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	8.00			8.00			0.43	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H9096	001	0	1	02	01	H9096_001_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H9096	001	0	1	02	01	H9096_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	001	0	1	02	01	H9096_001_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												30							30						30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	001	0	1	02	01	H9096_001_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	001	0	1	02	01	H9096_001_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9096	002	0	1	02	01	H9096_002_0	6			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	002	0	1	02	01	H9096_002_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	8.00			8.00			0.43	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H9096	002	0	1	02	01	H9096_002_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H9096	002	0	1	02	01	H9096_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	002	0	1	02	01	H9096_002_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												31							31						31																		31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	002	0	1	02	01	H9096_002_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	002	0	1	02	01	H9096_002_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9096	004	0	1	01	01	H9096_004_0	6			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	004	0	1	01	01	H9096_004_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H9096	004	0	1	01	01	H9096_004_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H9096	004	0	1	01	01	H9096_004_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	004	0	1	01	01	H9096_004_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												29							29						29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	004	0	1	01	01	H9096_004_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	004	0	1	01	01	H9096_004_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9096	005	0	1	01	01	H9096_005_0	6			Preferred Generic	4	01	1	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								7.00	14.00	7.00					0.00	0.00	0.00					7.00	14.00	0.00																	7.00			7.00			0.23	0.00	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	005	0	1	01	01	H9096_005_0	6			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								13.00	26.00	26.00					8.00	16.00	16.00					8.00	16.00	0.00																	13.00			13.00			0.43	0.27	0.27			0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													13.00	26.00	26.00	8.00	16.00	16.00	8.00	16.00	0.00				13.00		13.00
H9096	005	0	1	01	01	H9096_005_0	6			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	130.00					42.00	84.00	117.50					42.00	84.00	117.50																	47.00			47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	90.00				35.00		35.00
H9096	005	0	1	01	01	H9096_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	285.00																	100.00			100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	005	0	1	01	01	H9096_005_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31												33							33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	005	0	1	01	01	H9096_005_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	1		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9096	005	0	1	01	01	H9096_005_0	6			Vaccines ($0 cost sharing)	4	11	1	2	6	3		010	10	000		1				30												29	31								0.00							0.00																										0.00			0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9104	006	0	1	01	01	H9104_006_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9104	006	0	1	01	01	H9104_006_0	7			Preferred Generic	4	11	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9104	006	0	1	01	01	H9104_006_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9104	006	0	1	01	01	H9104_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	85.00	25.00	50.00	55.00	35.00	70.00	85.00	25.00	50.00	55.00	35.00		35.00
H9104	006	0	1	01	01	H9104_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9104	006	0	1	01	01	H9104_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9104	006	0	1	01	01	H9104_006_0	7			Select Care Drugs	4	10	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9179	001	0	1	01	01	H9179_001_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9179	001	0	1	01	01	H9179_001_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9179	001	0	1	01	01	H9179_001_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9179	001	0	1	01	01	H9179_001_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9179	001	0	1	01	01	H9179_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9179	001	0	1	01	01	H9179_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9179	002	0	1	01	01	H9179_002_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9179	002	0	1	01	01	H9179_002_0	8			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9179	002	0	1	01	01	H9179_002_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H9179	002	0	1	01	01	H9179_002_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9179	002	0	1	01	01	H9179_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9179	002	0	1	01	01	H9179_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9207	002	0	1	02	01	H9207_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	002	0	1	02	01	H9207_002_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	002	0	1	02	01	H9207_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H9207	002	0	1	02	01	H9207_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	002	0	1	02	01	H9207_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1180.04	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	002	0	1	02	01	H9207_002_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	002	0	1	02	01	H9207_002_0	10			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9207	012	0	1	02	01	H9207_012_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	012	0	1	02	01	H9207_012_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	012	0	1	02	01	H9207_012_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H9207	012	0	1	02	01	H9207_012_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	012	0	1	02	01	H9207_012_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1171.74	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	012	0	1	02	01	H9207_012_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	012	0	1	02	01	H9207_012_0	11			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9207	013	0	1	02	01	H9207_013_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	013	0	1	02	01	H9207_013_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	013	0	1	02	01	H9207_013_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H9207	013	0	1	02	01	H9207_013_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	013	0	1	02	01	H9207_013_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1139.75	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	013	0	1	02	01	H9207_013_0	10			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	013	0	1	02	01	H9207_013_0	10			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9207	014	0	1	02	01	H9207_014_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	014	0	1	02	01	H9207_014_0	11			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	014	0	1	02	01	H9207_014_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H9207	014	0	1	02	01	H9207_014_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	014	0	1	02	01	H9207_014_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1174.57	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	014	0	1	02	01	H9207_014_0	11			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	014	0	1	02	01	H9207_014_0	11			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9207	015	0	1	02	01	H9207_015_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	015	0	1	02	01	H9207_015_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	015	0	1	02	01	H9207_015_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	94.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
H9207	015	0	1	02	01	H9207_015_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	200.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	015	0	1	02	01	H9207_015_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				882.07	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	015	0	1	02	01	H9207_015_0	12			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9207	015	0	1	02	01	H9207_015_0	12			Select Care Drugs	4	11	1	2	6	3	111		01	111		1	30	60	100				1	2	31	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9219	001	0	1	04	01	H9219_001_0	9			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	001	0	1	04	01	H9219_001_0	9			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	001	0	1	04	01	H9219_001_0	9			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H9219	001	0	1	04	01	H9219_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	001	0	1	04	01	H9219_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	001	0	1	04	01	H9219_001_0	9			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	001	0	1	04	01	H9219_001_0	9			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9219	002	0	1	04	01	H9219_002_0	8			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	002	0	1	04	01	H9219_002_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								15.00	30.00	45.00					10.00	20.00	30.00					0.00	0.00	0.00																15.00				15.00			0.50	0.33	0.00			0.44	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	002	0	1	04	01	H9219_002_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35		35
H9219	002	0	1	04	01	H9219_002_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	002	0	1	04	01	H9219_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												27							27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	002	0	1	04	01	H9219_002_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9219	002	0	1	04	01	H9219_002_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9231	001	0	1	04	01	H9231_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	001	0	1	04	01	H9231_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9231	001	0	1	04	01	H9231_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	5.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	4.00	6.00				2.00	4.00	5.00				2.00		2.00
H9231	001	0	1	04	01	H9231_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	6.00																			2.00	4.00	5.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9231	001	0	1	04	01	H9231_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	001	0	1	04	01	H9231_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	001	0	1	04	01	H9231_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9231	002	0	1	04	01	H9231_002_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	002	0	1	04	01	H9231_002_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9231	002	0	1	04	01	H9231_002_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5		5
H9231	002	0	1	04	01	H9231_002_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9231	002	0	1	04	01	H9231_002_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9231	002	0	1	04	01	H9231_002_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9231	002	0	1	04	01	H9231_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H9231	005	0	1	04	01	H9231_005_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	005	0	1	04	01	H9231_005_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9231	005	0	1	04	01	H9231_005_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9231	005	0	1	04	01	H9231_005_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9231	005	0	1	04	01	H9231_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	005	0	1	04	01	H9231_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	005	0	1	04	01	H9231_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9231	006	0	1	04	01	H9231_006_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	006	0	1	04	01	H9231_006_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9231	006	0	1	04	01	H9231_006_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9231	006	0	1	04	01	H9231_006_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9231	006	0	1	04	01	H9231_006_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	006	0	1	04	01	H9231_006_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	006	0	1	04	01	H9231_006_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9231	007	0	1	04	01	H9231_007_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	007	0	1	04	01	H9231_007_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9231	007	0	1	04	01	H9231_007_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9231	007	0	1	04	01	H9231_007_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9231	007	0	1	04	01	H9231_007_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	007	0	1	04	01	H9231_007_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9231	007	0	1	04	01	H9231_007_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35		35
H9231	010	0	1	04	01	H9231_010_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9231	010	0	1	04	01	H9231_010_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9231	010	0	1	04	01	H9231_010_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9231	010	0	1	04	01	H9231_010_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9231	010	0	1	04	01	H9231_010_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	010	0	1	04	01	H9231_010_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9231	010	0	1	04	01	H9231_010_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9239	001	0	1	48	05	H9239_001_0	4			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9239	001	0	1	48	05	H9239_001_0	4			Brand Drugs	4	10		2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9239	001	0	1	48	05	H9239_001_0	4			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9258	001	0	1	01	01	H9258_001_0	18			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9258	001	0	1	01	01	H9258_001_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9258	001	0	1	01	01	H9258_001_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9258	001	0	1	01	01	H9258_001_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.53	50	50	50				82.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9258	001	0	1	01	01	H9258_001_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9258	001	0	1	01	01	H9258_001_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9306	001	0	1	01	01	H9306_001_0	6			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	3.00	3.00	0.00																			3.00	3.00	0.00																	3.00			3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9306	001	0	1	01	01	H9306_001_0	6			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	8.00	8.00	8.00																			8.00	8.00	8.00																	8.00			8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	8.00	8.00				8.00	8.00	8.00				8.00		8.00
H9306	001	0	1	01	01	H9306_001_0	6			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	47.00	94.00	94.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	94.00				35.00	70.00	94.00				35.00		35.00
H9306	001	0	1	01	01	H9306_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9306	001	0	1	01	01	H9306_001_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				207.04	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9306	002	0	1	01	01	H9306_002_0	6			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H9306	002	0	1	01	01	H9306_002_0	6			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9306	002	0	1	01	01	H9306_002_0	6			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	47.00	94.00	94.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	94.00				35.00	70.00	94.00				35.00		35.00
H9306	002	0	1	01	01	H9306_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9306	002	0	1	01	01	H9306_002_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				162.39	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H9306	002	0	1	01	01	H9306_002_0	6			Supplemental Drugs	4	01	2	2	6	1	010		10	010		1	30								30							10	31	10.00																					10.00																			10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H9306	005	0	1	01	01	H9306_005_0	6			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	3.00	3.00	0.00																			3.00	3.00	0.00																	3.00			3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9306	005	0	1	01	01	H9306_005_0	6			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	8.00	8.00	8.00																			8.00	8.00	8.00																	8.00			8.00		0.27			0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	8.00	8.00				8.00	8.00	8.00				8.00		8.00
H9306	005	0	1	01	01	H9306_005_0	6			Preferred Brand	4	11	1	2	3	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	47.00	94.00	94.00																			47.00	94.00	94.00																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	94.00				35.00	70.00	94.00				35.00		35.00
H9306	005	0	1	01	01	H9306_005_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31	100.00	200.00	300.00																			100.00	200.00	300.00																	100.00			100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9306	005	0	1	01	01	H9306_005_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				194.04	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9335	001	0	1	01	01	H9335_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	001	0	1	01	01	H9335_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	001	0	1	01	01	H9335_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9335	001	0	1	01	01	H9335_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											79.37	50	50	50				79.37	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9335	001	0	1	01	01	H9335_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9335	001	0	1	01	01	H9335_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	005	0	1	01	01	H9335_005_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	005	0	1	01	01	H9335_005_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					9.00	18.00	27.00											14.00	28.00	42.00				9.00	18.00	0.00				14.00				14.00			0.47	0.30		0.47	0.30	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	005	0	1	01	01	H9335_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9335	005	0	1	01	01	H9335_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											72.25	50	50	50				72.25	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9335	005	0	1	01	01	H9335_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9335	005	0	1	01	01	H9335_005_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	006	0	1	01	01	H9335_006_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	006	0	1	01	01	H9335_006_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9335	006	0	1	01	01	H9335_006_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H9335	006	0	1	01	01	H9335_006_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.36	44	44	44				98.36	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9335	006	0	1	01	01	H9335_006_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9335	006	0	1	01	01	H9335_006_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9357	001	0	1	04	01	H9357_001_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9357	001	0	1	04	01	H9357_001_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9357	001	0	1	04	01	H9357_001_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9357	001	0	1	04	01	H9357_001_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.01	50	50	50				97.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9357	001	0	1	04	01	H9357_001_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9357	001	0	1	04	01	H9357_001_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9364	001	0	1	01	01	H9364_001_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9364	001	0	1	01	01	H9364_001_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9364	001	0	1	01	01	H9364_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9364	001	0	1	01	01	H9364_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											91.49	50	50	50				91.49	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9364	001	0	1	01	01	H9364_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9364	001	0	1	01	01	H9364_001_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9364	004	0	1	01	01	H9364_004_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9364	004	0	1	01	01	H9364_004_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9364	004	0	1	01	01	H9364_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9364	004	0	1	01	01	H9364_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.10	50	50	50				92.10	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9364	004	0	1	01	01	H9364_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9364	004	0	1	01	01	H9364_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9387	001	0	1	04	01	H9387_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9387	001	0	1	04	01	H9387_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								14.00	28.00	42.00					9.00	18.00	27.00											14.00	28.00	42.00				9.00	18.00	0.00				14.00				14.00			0.47	0.30		0.47	0.30	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9387	001	0	1	04	01	H9387_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9387	001	0	1	04	01	H9387_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											92.26	50	50	50				92.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9387	001	0	1	04	01	H9387_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9387	001	0	1	04	01	H9387_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9403	003	0	1	01	01	H9403_003_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9403	003	0	1	01	01	H9403_003_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	50.00					0.00	0.00	0.00											20.00	40.00	50.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9403	003	0	1	01	01	H9403_003_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H9403	003	0	1	01	01	H9403_003_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9403	003	0	1	01	01	H9403_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.82	29						589.82	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9403	004	0	1	01	01	H9403_004_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	8.00					0.00	0.00	0.00											8.00	16.00	8.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9403	004	0	1	01	01	H9403_004_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	42.50					0.00	0.00	0.00											17.00	34.00	42.50				0.00	0.00	0.00				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9403	004	0	1	01	01	H9403_004_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H9403	004	0	1	01	01	H9403_004_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9403	004	0	1	01	01	H9403_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											955.84	33						955.84	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9414	001	0	1	04	01	H9414_001_0	10			Preferred Generic	4	01	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	001	0	1	04	01	H9414_001_0	10			Generic	4	01	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	001	0	1	04	01	H9414_001_0	10			Preferred Brand	4	10	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	131.00																			47.00	94.00	131.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9414	001	0	1	04	01	H9414_001_0	10			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	290.00																			100.00	200.00	290.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	001	0	1	04	01	H9414_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	002	0	1	04	01	H9414_002_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	002	0	1	04	01	H9414_002_0	11			Generic	4	01	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	002	0	1	04	01	H9414_002_0	11			Preferred Brand	4	10	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9414	002	0	1	04	01	H9414_002_0	11			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9414	002	0	1	04	01	H9414_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9428	001	0	1	04	01	H9428_001_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9428	001	0	1	04	01	H9428_001_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9428	001	0	1	04	01	H9428_001_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9428	001	0	1	04	01	H9428_001_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											89.26	50	50	50				89.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9428	001	0	1	04	01	H9428_001_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9428	001	0	1	04	01	H9428_001_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9428	001	0	1	04	01	H9428_001_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9428	002	0	1	04	01	H9428_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9428	002	0	1	04	01	H9428_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9428	002	0	1	04	01	H9428_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9428	002	0	1	04	01	H9428_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											77.11	50	50	50				77.11	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9428	002	0	1	04	01	H9428_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9428	002	0	1	04	01	H9428_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9428	002	0	1	04	01	H9428_002_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9431	001	0	1	04	01	H9431_001_0	8			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	001	0	1	04	01	H9431_001_0	8			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	001	0	1	04	01	H9431_001_0	8			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	001	0	1	04	01	H9431_001_0	8			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	001	0	1	04	01	H9431_001_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	001	0	1	04	01	H9431_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	001	0	1	04	01	H9431_001_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											720.07	28						568.10	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	002	0	1	04	01	H9431_002_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	002	0	1	04	01	H9431_002_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	002	0	1	04	01	H9431_002_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	002	0	1	04	01	H9431_002_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	002	0	1	04	01	H9431_002_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	002	0	1	04	01	H9431_002_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	002	0	1	04	01	H9431_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											816.14	30						598.81	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	004	0	1	04	01	H9431_004_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	004	0	1	04	01	H9431_004_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	004	0	1	04	01	H9431_004_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	004	0	1	04	01	H9431_004_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	004	0	1	04	01	H9431_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	004	0	1	04	01	H9431_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	004	0	1	04	01	H9431_004_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											714.67	30						537.24	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	005	0	1	04	01	H9431_005_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	005	0	1	04	01	H9431_005_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	005	0	1	04	01	H9431_005_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	005	0	1	04	01	H9431_005_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	005	0	1	04	01	H9431_005_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	005	0	1	04	01	H9431_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	005	0	1	04	01	H9431_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											722.04	30						591.36	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	006	0	1	04	01	H9431_006_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	006	0	1	04	01	H9431_006_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	006	0	1	04	01	H9431_006_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	006	0	1	04	01	H9431_006_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	006	0	1	04	01	H9431_006_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	006	0	1	04	01	H9431_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	006	0	1	04	01	H9431_006_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											797.93	30						612.63	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	013	0	1	04	01	H9431_013_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	013	0	1	04	01	H9431_013_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	013	0	1	04	01	H9431_013_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	013	0	1	04	01	H9431_013_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	013	0	1	04	01	H9431_013_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	013	0	1	04	01	H9431_013_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	013	0	1	04	01	H9431_013_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.41	33						638.19	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	014	0	1	04	01	H9431_014_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	014	0	1	04	01	H9431_014_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	014	0	1	04	01	H9431_014_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	014	0	1	04	01	H9431_014_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	014	0	1	04	01	H9431_014_0	7			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	014	0	1	04	01	H9431_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	014	0	1	04	01	H9431_014_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											790.27	33						670.81	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	018	0	1	04	01	H9431_018_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	018	0	1	04	01	H9431_018_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	018	0	1	04	01	H9431_018_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	018	0	1	04	01	H9431_018_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	018	0	1	04	01	H9431_018_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											86.03	25	25	25				76.26	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	018	0	1	04	01	H9431_018_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.29	50	50	50				26.77	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	018	0	1	04	01	H9431_018_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											841.89	33						646.98	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9431	019	0	1	04	01	H9431_019_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	019	0	1	04	01	H9431_019_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	019	0	1	04	01	H9431_019_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	019	0	1	04	01	H9431_019_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					10.00	20.00	30.00											10.00	20.00	30.00				10.00	10.00	10.00					10.00			10.00			0.33	0.33		0.33	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9431	019	0	1	04	01	H9431_019_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											103.12	25	25	25				92.46	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9431	019	0	1	04	01	H9431_019_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.43	50	50	50				51.22	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9431	019	0	1	04	01	H9431_019_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											836.35	29						584.36	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9460	001	0	1	01	01	H9460_001_0	8			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9460	001	0	1	01	01	H9460_001_0	8			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9460	001	0	1	01	01	H9460_001_0	8			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H9460	001	0	1	01	01	H9460_001_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9460	001	0	1	01	01	H9460_001_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9460	001	0	1	01	01	H9460_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.05	33						431.22	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9469	001	0	1	04	01	H9469_001_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	001	0	1	04	01	H9469_001_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	001	0	1	04	01	H9469_001_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10.00		10.00
H9469	001	0	1	04	01	H9469_001_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	001	0	1	04	01	H9469_001_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	001	0	1	04	01	H9469_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	002	0	1	04	01	H9469_002_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	002	0	1	04	01	H9469_002_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	002	0	1	04	01	H9469_002_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	002	0	1	04	01	H9469_002_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	002	0	1	04	01	H9469_002_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	002	0	1	04	01	H9469_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	003	0	1	04	01	H9469_003_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	003	0	1	04	01	H9469_003_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	003	0	1	04	01	H9469_003_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	003	0	1	04	01	H9469_003_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	003	0	1	04	01	H9469_003_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	003	0	1	04	01	H9469_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	004	0	1	04	01	H9469_004_0	5			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	004	0	1	04	01	H9469_004_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	004	0	1	04	01	H9469_004_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	004	0	1	04	01	H9469_004_0	5			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	004	0	1	04	01	H9469_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	005	0	1	04	01	H9469_005_0	5			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	005	0	1	04	01	H9469_005_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	005	0	1	04	01	H9469_005_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	005	0	1	04	01	H9469_005_0	5			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	005	0	1	04	01	H9469_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	006	0	1	04	01	H9469_006_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	006	0	1	04	01	H9469_006_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	006	0	1	04	01	H9469_006_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	006	0	1	04	01	H9469_006_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	006	0	1	04	01	H9469_006_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	006	0	1	04	01	H9469_006_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	007	0	1	04	01	H9469_007_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	007	0	1	04	01	H9469_007_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	007	0	1	04	01	H9469_007_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	007	0	1	04	01	H9469_007_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	007	0	1	04	01	H9469_007_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	007	0	1	04	01	H9469_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	008	0	1	04	01	H9469_008_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	008	0	1	04	01	H9469_008_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	008	0	1	04	01	H9469_008_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	008	0	1	04	01	H9469_008_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	008	0	1	04	01	H9469_008_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	008	0	1	04	01	H9469_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	009	0	1	04	01	H9469_009_0	4			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9469	009	0	1	04	01	H9469_009_0	4			Preferred Generic	4	11	3	2	1	3	111		01	111		1	30	60	100				2	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9469	009	0	1	04	01	H9469_009_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	10.00	20.00	30.00																			0.00	0.00	0.00																10.00				10.00		0.33			0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	30.00				0.00	0.00	0.00				10		10
H9469	009	0	1	04	01	H9469_009_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	47.00	94.00	141.00																			47.00	141.00	141.00																47.00				47.00		1.57			1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35		35
H9469	009	0	1	04	01	H9469_009_0	4			Non-Preferred Brand	4	11	1	2	4	1	010		01	010		1	30								30						30		34	100.00																					100.00																		100.00				100.00		3.33			3.33			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35		35
H9469	009	0	1	04	01	H9469_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9485	001	0	1	04	01	H9485_001_0	12			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9485	001	0	1	04	01	H9485_001_0	12			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9485	001	0	1	04	01	H9485_001_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9485	001	0	1	04	01	H9485_001_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9485	001	0	1	04	01	H9485_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1155.29	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9485	002	0	1	04	01	H9485_002_0	11			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9485	002	0	1	04	01	H9485_002_0	11			Generic	4	01	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9485	002	0	1	04	01	H9485_002_0	11			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	37.00	74.00	111.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9485	002	0	1	04	01	H9485_002_0	11			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9485	002	0	1	04	01	H9485_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1298.36	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9489	001	0	1	01	01	H9489_001_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9489	001	0	1	01	01	H9489_001_0	9			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			10.00	20.00	25.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9489	001	0	1	01	01	H9489_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	118.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9489	001	0	1	01	01	H9489_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9489	001	0	1	01	01	H9489_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				881.92	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9489	001	0	1	01	01	H9489_001_0	9			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	004	0	1	01	01	H9525_004_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	004	0	1	01	01	H9525_004_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	004	0	1	01	01	H9525_004_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	004	0	1	01	01	H9525_004_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	004	0	1	01	01	H9525_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	004	0	1	01	01	H9525_004_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	004	0	1	01	01	H9525_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	004	0	1	01	01	H9525_004_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	004	0	1	01	01	H9525_004_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	006	0	1	01	01	H9525_006_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	006	0	1	01	01	H9525_006_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	006	0	1	01	01	H9525_006_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	006	0	1	01	01	H9525_006_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	006	0	1	01	01	H9525_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	006	0	1	01	01	H9525_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	006	0	1	01	01	H9525_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	006	0	1	01	01	H9525_006_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	006	0	1	01	01	H9525_006_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	011	0	1	01	01	H9525_011_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								7.00	14.00	21.00					2.00	4.00	6.00					0.00	0.00	0.00																7.00				7.00			0.23	0.07	0.00			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	011	0	1	01	01	H9525_011_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.00	28.00	42.00					9.00	18.00	27.00					0.00	0.00	0.00																14.00				14.00			0.47	0.30	0.00			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	011	0	1	01	01	H9525_011_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	011	0	1	01	01	H9525_011_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	011	0	1	01	01	H9525_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	011	0	1	01	01	H9525_011_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	011	0	1	01	01	H9525_011_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	1	1	01	01	H9525_013_1	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	1	1	01	01	H9525_013_1	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	1	1	01	01	H9525_013_1	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	1	1	01	01	H9525_013_1	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	1	1	01	01	H9525_013_1	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	013	1	1	01	01	H9525_013_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	1	1	01	01	H9525_013_1	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	1	1	01	01	H9525_013_1	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	1	1	01	01	H9525_013_1	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	2	1	01	01	H9525_013_2	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	2	1	01	01	H9525_013_2	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	2	1	01	01	H9525_013_2	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	2	1	01	01	H9525_013_2	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	2	1	01	01	H9525_013_2	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	013	2	1	01	01	H9525_013_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	2	1	01	01	H9525_013_2	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	2	1	01	01	H9525_013_2	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	2	1	01	01	H9525_013_2	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	3	1	01	01	H9525_013_3	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	3	1	01	01	H9525_013_3	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	3	1	01	01	H9525_013_3	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	3	1	01	01	H9525_013_3	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	3	1	01	01	H9525_013_3	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	013	3	1	01	01	H9525_013_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	3	1	01	01	H9525_013_3	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	3	1	01	01	H9525_013_3	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	3	1	01	01	H9525_013_3	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	4	1	01	01	H9525_013_4	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	4	1	01	01	H9525_013_4	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	4	1	01	01	H9525_013_4	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	4	1	01	01	H9525_013_4	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	013	4	1	01	01	H9525_013_4	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	013	4	1	01	01	H9525_013_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	4	1	01	01	H9525_013_4	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	4	1	01	01	H9525_013_4	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	013	4	1	01	01	H9525_013_4	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	015	0	1	01	01	H9525_015_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	015	0	1	01	01	H9525_015_0	7			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	015	0	1	01	01	H9525_015_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	015	0	1	01	01	H9525_015_0	7			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	015	0	1	01	01	H9525_015_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	015	0	1	01	01	H9525_015_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	015	0	1	01	01	H9525_015_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	015	0	1	01	01	H9525_015_0	7			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	015	0	1	01	01	H9525_015_0	7			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	017	0	1	01	01	H9525_017_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	017	0	1	01	01	H9525_017_0	6			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9525	017	0	1	01	01	H9525_017_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	017	0	1	01	01	H9525_017_0	6			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		34								12.50	25.00	37.50					7.50	15.00	22.50					0.00	0.00	0.00																12.50				12.50			0.42	0.25	0.00			0.37	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9525	017	0	1	01	01	H9525_017_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	70.00	70.00																35.00				35.00			1.17	1.17	1.17			1.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9525	017	0	1	01	01	H9525_017_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								95.00	190.00	285.00					85.00	170.00	255.00					85.00	170.00	170.00																95.00				95.00			3.17	2.83	2.83			2.79	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	017	0	1	01	01	H9525_017_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	017	0	1	01	01	H9525_017_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9525	017	0	1	01	01	H9525_017_0	6			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9572	001	1	1	04	01	H9572_001_1	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	1	1	04	01	H9572_001_1	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	001	1	1	04	01	H9572_001_1	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					10.00		0.00											18.00		54.00				10.00		0.00				18.00				18.00			0.58	0.32		0.58	0.32	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	1	1	04	01	H9572_001_1	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	001	1	1	04	01	H9572_001_1	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											67.00	48		48				67.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	001	1	1	04	01	H9572_001_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	001	2	1	04	01	H9572_001_2	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	2	1	04	01	H9572_001_2	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	001	2	1	04	01	H9572_001_2	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					10.00		0.00											18.00		54.00				10.00		0.00				18.00				18.00			0.58	0.32		0.58	0.32	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	2	1	04	01	H9572_001_2	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	001	2	1	04	01	H9572_001_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											67.00	48		48				67.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	001	2	1	04	01	H9572_001_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	001	3	1	04	01	H9572_001_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	3	1	04	01	H9572_001_3	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	001	3	1	04	01	H9572_001_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					10.00		0.00											18.00		54.00				10.00		0.00				18.00				18.00			0.58	0.32		0.58	0.32	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	3	1	04	01	H9572_001_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	001	3	1	04	01	H9572_001_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											67.00	48		48				67.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	001	3	1	04	01	H9572_001_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	001	4	1	04	01	H9572_001_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	4	1	04	01	H9572_001_4	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	001	4	1	04	01	H9572_001_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					10.00		0.00											18.00		54.00				10.00		0.00				18.00				18.00			0.58	0.32		0.58	0.32	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	4	1	04	01	H9572_001_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	001	4	1	04	01	H9572_001_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											67.00	48		48				67.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	001	4	1	04	01	H9572_001_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	001	6	1	04	01	H9572_001_6	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	6	1	04	01	H9572_001_6	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	001	6	1	04	01	H9572_001_6	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					10.00		0.00											18.00		54.00				10.00		0.00				18.00				18.00			0.58	0.32		0.58	0.32	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	001	6	1	04	01	H9572_001_6	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	001	6	1	04	01	H9572_001_6	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											67.00	48		48				67.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	001	6	1	04	01	H9572_001_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	002	1	1	04	01	H9572_002_1	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	1	1	04	01	H9572_002_1	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	002	1	1	04	01	H9572_002_1	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	1	1	04	01	H9572_002_1	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	002	1	1	04	01	H9572_002_1	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											66.00	50		50				66.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	002	1	1	04	01	H9572_002_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	002	2	1	04	01	H9572_002_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	2	1	04	01	H9572_002_2	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	002	2	1	04	01	H9572_002_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	2	1	04	01	H9572_002_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	002	2	1	04	01	H9572_002_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											66.00	50		50				66.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	002	2	1	04	01	H9572_002_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	002	3	1	04	01	H9572_002_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	3	1	04	01	H9572_002_3	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	002	3	1	04	01	H9572_002_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	3	1	04	01	H9572_002_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	002	3	1	04	01	H9572_002_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											66.00	50		50				66.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	002	3	1	04	01	H9572_002_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	002	4	1	04	01	H9572_002_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	4	1	04	01	H9572_002_4	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	002	4	1	04	01	H9572_002_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	4	1	04	01	H9572_002_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	002	4	1	04	01	H9572_002_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											66.00	50		50				66.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	002	4	1	04	01	H9572_002_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	002	6	1	04	01	H9572_002_6	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	6	1	04	01	H9572_002_6	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	002	6	1	04	01	H9572_002_6	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	002	6	1	04	01	H9572_002_6	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	002	6	1	04	01	H9572_002_6	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											66.00	50		50				66.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	002	6	1	04	01	H9572_002_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	003	1	1	04	01	H9572_003_1	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	1	1	04	01	H9572_003_1	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	003	1	1	04	01	H9572_003_1	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	1	1	04	01	H9572_003_1	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								42.00		126.00					37.00		111.00											42.00		126.00				37.00		74.00				42.00				42.00			1.35	1.19		1.35	1.19	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		74.00	35.00		35.00
H9572	003	1	1	04	01	H9572_003_1	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											63.00	45		45				69.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	003	1	1	04	01	H9572_003_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	003	2	1	04	01	H9572_003_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	2	1	04	01	H9572_003_2	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	003	2	1	04	01	H9572_003_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	2	1	04	01	H9572_003_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								42.00		126.00					37.00		111.00											42.00		126.00				37.00		74.00				42.00				42.00			1.35	1.19		1.35	1.19	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		74.00	35.00		35.00
H9572	003	2	1	04	01	H9572_003_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											63.00	45		45				69.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	003	2	1	04	01	H9572_003_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	003	3	1	04	01	H9572_003_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	3	1	04	01	H9572_003_3	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	003	3	1	04	01	H9572_003_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	3	1	04	01	H9572_003_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								42.00		126.00					37.00		111.00											42.00		126.00				37.00		74.00				42.00				42.00			1.35	1.19		1.35	1.19	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		74.00	35.00		35.00
H9572	003	3	1	04	01	H9572_003_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											63.00	45		45				69.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	003	3	1	04	01	H9572_003_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	003	4	1	04	01	H9572_003_4	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	4	1	04	01	H9572_003_4	5			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	003	4	1	04	01	H9572_003_4	5			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	4	1	04	01	H9572_003_4	5			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								42.00		126.00					37.00		111.00											42.00		126.00				37.00		74.00				42.00				42.00			1.35	1.19		1.35	1.19	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		74.00	35.00		35.00
H9572	003	4	1	04	01	H9572_003_4	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											63.00	45		45				69.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	003	4	1	04	01	H9572_003_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	003	6	1	04	01	H9572_003_6	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	6	1	04	01	H9572_003_6	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	003	6	1	04	01	H9572_003_6	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								12.00		36.00					7.00		0.00											12.00		36.00				7.00		0.00				12.00				12.00			0.39	0.23		0.39	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	003	6	1	04	01	H9572_003_6	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								42.00		126.00					37.00		111.00											42.00		126.00				37.00		74.00				42.00				42.00			1.35	1.19		1.35	1.19	1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		74.00	35.00		35.00
H9572	003	6	1	04	01	H9572_003_6	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											63.00	45		45				69.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	003	6	1	04	01	H9572_003_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	004	1	1	04	01	H9572_004_1	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	1	1	04	01	H9572_004_1	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	004	1	1	04	01	H9572_004_1	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	1	1	04	01	H9572_004_1	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	004	1	1	04	01	H9572_004_1	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											79.00	50		50				71.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	004	1	1	04	01	H9572_004_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	004	2	1	04	01	H9572_004_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	2	1	04	01	H9572_004_2	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	004	2	1	04	01	H9572_004_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	2	1	04	01	H9572_004_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	004	2	1	04	01	H9572_004_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											79.00	50		50				71.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	004	2	1	04	01	H9572_004_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	004	3	1	04	01	H9572_004_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	3	1	04	01	H9572_004_3	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	004	3	1	04	01	H9572_004_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	3	1	04	01	H9572_004_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	004	3	1	04	01	H9572_004_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											79.00	50		50				71.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	004	3	1	04	01	H9572_004_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	004	4	1	04	01	H9572_004_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	4	1	04	01	H9572_004_4	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	004	4	1	04	01	H9572_004_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	4	1	04	01	H9572_004_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	004	4	1	04	01	H9572_004_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											79.00	50		50				71.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	004	4	1	04	01	H9572_004_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	004	6	1	04	01	H9572_004_6	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	6	1	04	01	H9572_004_6	4			Preferred Generic	4	01	1	2	1	3		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2																	
H9572	004	6	1	04	01	H9572_004_6	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	004	6	1	04	01	H9572_004_6	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	004	6	1	04	01	H9572_004_6	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											79.00	50		50				71.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	004	6	1	04	01	H9572_004_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	006	1	1	04	01	H9572_006_1	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	1	1	04	01	H9572_006_1	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	1	1	04	01	H9572_006_1	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H9572	006	1	1	04	01	H9572_006_1	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											98.00	50		50				92.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	006	1	1	04	01	H9572_006_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	006	2	1	04	01	H9572_006_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	2	1	04	01	H9572_006_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	2	1	04	01	H9572_006_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H9572	006	2	1	04	01	H9572_006_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											98.00	50		50				92.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	006	2	1	04	01	H9572_006_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	006	3	1	04	01	H9572_006_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	3	1	04	01	H9572_006_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	3	1	04	01	H9572_006_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H9572	006	3	1	04	01	H9572_006_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											98.00	50		50				92.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	006	3	1	04	01	H9572_006_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	006	4	1	04	01	H9572_006_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	4	1	04	01	H9572_006_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	4	1	04	01	H9572_006_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H9572	006	4	1	04	01	H9572_006_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											98.00	50		50				92.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	006	4	1	04	01	H9572_006_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	006	6	1	04	01	H9572_006_6	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	6	1	04	01	H9572_006_6	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					10.00		0.00											20.00		60.00				10.00		0.00				20.00				20.00			0.65	0.32		0.65	0.32	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	006	6	1	04	01	H9572_006_6	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		90.00				47.00				47.00			1.52	1.45		1.52	1.45	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		90.00	35.00		35.00
H9572	006	6	1	04	01	H9572_006_6	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											98.00	50		50				92.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	006	6	1	04	01	H9572_006_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	007	1	1	04	01	H9572_007_1	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	1	1	04	01	H9572_007_1	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	1	1	04	01	H9572_007_1	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	007	1	1	04	01	H9572_007_1	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											68.00	50		50				64.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	007	1	1	04	01	H9572_007_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	007	2	1	04	01	H9572_007_2	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	2	1	04	01	H9572_007_2	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	2	1	04	01	H9572_007_2	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	007	2	1	04	01	H9572_007_2	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											68.00	50		50				64.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	007	2	1	04	01	H9572_007_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	007	3	1	04	01	H9572_007_3	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	3	1	04	01	H9572_007_3	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	3	1	04	01	H9572_007_3	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	007	3	1	04	01	H9572_007_3	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											68.00	50		50				64.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	007	3	1	04	01	H9572_007_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	007	4	1	04	01	H9572_007_4	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	4	1	04	01	H9572_007_4	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	4	1	04	01	H9572_007_4	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	007	4	1	04	01	H9572_007_4	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											68.00	50		50				64.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	007	4	1	04	01	H9572_007_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9572	007	6	1	04	01	H9572_007_6	4			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	6	1	04	01	H9572_007_6	4			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					11.00		0.00											20.00		60.00				11.00		0.00				20.00				20.00			0.65	0.35		0.65	0.35	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9572	007	6	1	04	01	H9572_007_6	4			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		84.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		84.00	35.00		35.00
H9572	007	6	1	04	01	H9572_007_6	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											68.00	50		50				64.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
H9572	007	6	1	04	01	H9572_007_6	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9576	001	0	1	48	05	H9576_001_0	8			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9576	001	0	1	48	05	H9576_001_0	8			Brand Drugs	4	10		2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9576	001	0	1	48	05	H9576_001_0	8			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9589	003	0	1	04	01	H9589_003_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								5.00	10.00	5.00					0.00	0.00	0.00											5.00	10.00	5.00				0.00	0.00	0.00				0.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9589	003	0	1	04	01	H9589_003_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								17.00	34.00	42.50					0.00	0.00	0.00											17.00	34.00	42.50				0.00	0.00	0.00				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9589	003	0	1	04	01	H9589_003_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	117.50					42.00	84.00	105.00											47.00	94.00	117.50				42.00	84.00	105.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
H9589	003	0	1	04	01	H9589_003_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	250.00					95.00	190.00	237.50											100.00	200.00	250.00				95.00	190.00	237.50				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9589	003	0	1	04	01	H9589_003_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											836.64	29						836.64	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9614	001	0	1	04	01	H9614_001_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9614	001	0	1	04	01	H9614_001_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9614	001	0	1	04	01	H9614_001_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9614	001	0	1	04	01	H9614_001_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9614	001	0	1	04	01	H9614_001_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9614	001	0	1	04	01	H9614_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				831.70	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9614	001	0	1	04	01	H9614_001_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9614	001	0	1	04	01	H9614_001_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9615	007	0	1	04	01	H9615_007_0	11			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	007	0	1	04	01	H9615_007_0	11			Preferred Generic	4	01	1	2	1	3	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9615	007	0	1	04	01	H9615_007_0	11			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H9615	007	0	1	04	01	H9615_007_0	11			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	35.00		105.00																			35.00		70.00																35.00				35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	007	0	1	04	01	H9615_007_0	11			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				110.51	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	007	0	1	04	01	H9615_007_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1661.28	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	008	0	1	04	01	H9615_008_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	008	0	1	04	01	H9615_008_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	12.00		36.00																			12.00		24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				12.00		24.00				12.00		12.00
H9615	008	0	1	04	01	H9615_008_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	008	0	1	04	01	H9615_008_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				117.97	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	008	0	1	04	01	H9615_008_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1373.95	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	010	0	1	04	01	H9615_010_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	010	0	1	04	01	H9615_010_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	12.00		36.00																			12.00		24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				12.00		24.00				12.00		12.00
H9615	010	0	1	04	01	H9615_010_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	010	0	1	04	01	H9615_010_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				104.45	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	010	0	1	04	01	H9615_010_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				945.43	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	012	0	1	04	01	H9615_012_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	012	0	1	04	01	H9615_012_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H9615	012	0	1	04	01	H9615_012_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	012	0	1	04	01	H9615_012_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				110.70	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	012	0	1	04	01	H9615_012_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1220.97	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	014	0	1	04	01	H9615_014_0	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	014	0	1	04	01	H9615_014_0	10			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		30.00				15.00		15.00
H9615	014	0	1	04	01	H9615_014_0	10			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	014	0	1	04	01	H9615_014_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				110.75	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	014	0	1	04	01	H9615_014_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1368.07	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	015	0	1	04	01	H9615_015_0	14			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	015	0	1	04	01	H9615_015_0	14			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H9615	015	0	1	04	01	H9615_015_0	14			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	015	0	1	04	01	H9615_015_0	14			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	015	0	1	04	01	H9615_015_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1425.08	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	016	0	1	04	01	H9615_016_0	13			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	016	0	1	04	01	H9615_016_0	13			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H9615	016	0	1	04	01	H9615_016_0	13			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	42.00		126.00																			42.00		84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	016	0	1	04	01	H9615_016_0	13			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	016	0	1	04	01	H9615_016_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1182.55	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	017	0	1	04	01	H9615_017_0	12			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	017	0	1	04	01	H9615_017_0	12			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	10.00		30.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		20.00				10.00		10.00
H9615	017	0	1	04	01	H9615_017_0	12			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	40.00		120.00																			40.00		80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	017	0	1	04	01	H9615_017_0	12			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	017	0	1	04	01	H9615_017_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1274.36	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	018	0	1	04	01	H9615_018_0	11			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	018	0	1	04	01	H9615_018_0	11			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	15.00		45.00																			15.00		30.00																15.00				15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				15.00		30.00				15.00		15.00
H9615	018	0	1	04	01	H9615_018_0	11			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	45.00		135.00																			45.00		90.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	018	0	1	04	01	H9615_018_0	11			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				109.58	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	018	0	1	04	01	H9615_018_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1114.67	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9615	019	0	1	04	01	H9615_019_0	11			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
H9615	019	0	1	04	01	H9615_019_0	11			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	12.00		36.00																			12.00		24.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				12.00		24.00				12.00		12.00
H9615	019	0	1	04	01	H9615_019_0	11			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				2	2	30		90				30		31	42.00		126.00																			42.00		84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	019	0	1	04	01	H9615_019_0	11			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				2	2	30		90				30		31	100.00		300.00																			100.00		200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
H9615	019	0	1	04	01	H9615_019_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1526.16	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9630	002	0	1	01	01	H9630_002_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	002	0	1	01	01	H9630_002_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	0.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	002	0	1	01	01	H9630_002_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9630	002	0	1	01	01	H9630_002_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											70.13	50	50	50				70.13	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9630	002	0	1	01	01	H9630_002_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9630	002	0	1	01	01	H9630_002_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	005	0	1	01	01	H9630_005_0	5			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	005	0	1	01	01	H9630_005_0	5			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	005	0	1	01	01	H9630_005_0	5			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H9630	005	0	1	01	01	H9630_005_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											79.74	50	50	50				79.74	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9630	005	0	1	01	01	H9630_005_0	5			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9630	005	0	1	01	01	H9630_005_0	5			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	008	0	1	01	01	H9630_008_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	008	0	1	01	01	H9630_008_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	0.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	008	0	1	01	01	H9630_008_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9630	008	0	1	01	01	H9630_008_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											71.97	50	50	50				71.97	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9630	008	0	1	01	01	H9630_008_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9630	008	0	1	01	01	H9630_008_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	013	0	1	01	01	H9630_013_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	013	0	1	01	01	H9630_013_0	16			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H9630	013	0	1	01	01	H9630_013_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	0.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	013	0	1	01	01	H9630_013_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35		35
H9630	013	0	1	01	01	H9630_013_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											80.67	50	50	50				80.67	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9630	013	0	1	01	01	H9630_013_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35		35
H9630	013	0	1	01	01	H9630_013_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9630	013	0	1	01	01	H9630_013_0	16			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9678	001	0	1	04	01	H9678_001_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9678	001	0	1	04	01	H9678_001_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	10.00																			10.00	20.00	10.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													10.00	20.00	10.00				10.00	20.00	10.00				10.00		10.00
H9678	001	0	1	04	01	H9678_001_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	47.00																			47.00	94.00	47.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H9678	001	0	1	04	01	H9678_001_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H9678	001	0	1	04	01	H9678_001_0	12			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31					26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs													35.00	70.00	35.00				35.00	70.00	35.00				35.00		35.00
H9678	001	0	1	04	01	H9678_001_0	12			Supplemental Drugs	4	01	2	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																											
H9678	001	0	1	04	01	H9678_001_0	12			Supplemental Drugs	4	01	2	2	6	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs										1																	
H9686	001	0	1	01	01	H9686_001_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9686	001	0	1	01	01	H9686_001_0	12			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9686	001	0	1	01	01	H9686_001_0	12			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9686	001	0	1	01	01	H9686_001_0	12			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9686	001	0	1	01	01	H9686_001_0	12			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9686	001	0	1	01	01	H9686_001_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				711.92	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9686	001	0	1	01	01	H9686_001_0	12			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9686	001	0	1	01	01	H9686_001_0	12			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9686	004	0	1	01	01	H9686_004_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9686	004	0	1	01	01	H9686_004_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9686	004	0	1	01	01	H9686_004_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9686	004	0	1	01	01	H9686_004_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	120.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9686	004	0	1	01	01	H9686_004_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9686	004	0	1	01	01	H9686_004_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				703.44	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9686	004	0	1	01	01	H9686_004_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9686	004	0	1	01	01	H9686_004_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9699	007	0	1	01	01	H9699_007_0	3			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	3.00		6.00																			3.00		6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9699	007	0	1	01	01	H9699_007_0	3			Generic	4	11	3	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	10.00		20.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9699	007	0	1	01	01	H9699_007_0	3			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		94.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00				35.00		70.00				35.00		35.00
H9699	007	0	1	01	01	H9699_007_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				63.94	36		36																		36		36															36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		70.00				35.00		70.00				35.00		35.00
H9699	007	0	1	01	01	H9699_007_0	3			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				903.44	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H9699	007	0	1	01	01	H9699_007_0	3			Select Care Drugs	4	11	1	2	6	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9699	007	0	1	01	01	H9699_007_0	3			Select Care Drugs	4	11	1	2	6	3	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9706	001	0	1	01	01	H9706_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
H9706	001	0	1	01	01	H9706_001_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9706	001	0	1	01	01	H9706_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	40.00				8.00	16.00	16.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	40.00	8.00	16.00	16.00	20.00		20.00
H9706	001	0	1	01	01	H9706_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	94.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00
H9706	001	0	1	01	01	H9706_001_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	001	0	1	01	01	H9706_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9706	005	0	1	01	01	H9706_005_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H9706	005	0	1	01	01	H9706_005_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H9706	005	0	1	01	01	H9706_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	005	0	1	01	01	H9706_005_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	005	0	1	01	01	H9706_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9706	007	0	1	01	01	H9706_007_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H9706	007	0	1	01	01	H9706_007_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H9706	007	0	1	01	01	H9706_007_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	007	0	1	01	01	H9706_007_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	007	0	1	01	01	H9706_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9706	008	0	1	01	01	H9706_008_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H9706	008	0	1	01	01	H9706_008_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H9706	008	0	1	01	01	H9706_008_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	008	0	1	01	01	H9706_008_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	008	0	1	01	01	H9706_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9706	009	0	1	01	01	H9706_009_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
H9706	009	0	1	01	01	H9706_009_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
H9706	009	0	1	01	01	H9706_009_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	009	0	1	01	01	H9706_009_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9706	009	0	1	01	01	H9706_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9712	001	0	1	48	05	H9712_001_0	13			Generic Drugs	4	01		2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9712	001	0	1	48	05	H9712_001_0	13			Brand Drugs	4	10		2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31																																														0.00			0.00			0.00	Generic Drugs, Brand Drugs	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9725	006	0	1	01	01	H9725_006_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	006	0	1	01	01	H9725_006_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	006	0	1	01	01	H9725_006_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H9725	006	0	1	01	01	H9725_006_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	006	0	1	01	01	H9725_006_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	006	0	1	01	01	H9725_006_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											544.82	33						426.87	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	008	0	1	01	01	H9725_008_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	008	0	1	01	01	H9725_008_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H9725	008	0	1	01	01	H9725_008_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	0.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	10.00	20.00	30.00	20.00	40.00	60.00	10.00	20.00	0.00	20.00		20.00
H9725	008	0	1	01	01	H9725_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	008	0	1	01	01	H9725_008_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					99.00	198.00	297.00											100.00	200.00	300.00				99.00	198.00	297.00				100.00				100.00			3.33	3.30		3.33	3.30	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	008	0	1	01	01	H9725_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											730.66	33						509.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	009	1	1	01	01	H9725_009_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	009	1	1	01	01	H9725_009_1	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	009	1	1	01	01	H9725_009_1	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H9725	009	1	1	01	01	H9725_009_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	1	1	01	01	H9725_009_1	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	1	1	01	01	H9725_009_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											571.69	33						524.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	009	2	1	01	01	H9725_009_2	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	009	2	1	01	01	H9725_009_2	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	009	2	1	01	01	H9725_009_2	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H9725	009	2	1	01	01	H9725_009_2	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	2	1	01	01	H9725_009_2	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	2	1	01	01	H9725_009_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											571.69	33						524.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	009	3	1	01	01	H9725_009_3	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	009	3	1	01	01	H9725_009_3	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	009	3	1	01	01	H9725_009_3	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H9725	009	3	1	01	01	H9725_009_3	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	3	1	01	01	H9725_009_3	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	3	1	01	01	H9725_009_3	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											571.69	33						524.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	009	4	1	01	01	H9725_009_4	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	009	4	1	01	01	H9725_009_4	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	009	4	1	01	01	H9725_009_4	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H9725	009	4	1	01	01	H9725_009_4	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	4	1	01	01	H9725_009_4	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	009	4	1	01	01	H9725_009_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											571.69	33						524.12	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	010	0	1	01	01	H9725_010_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H9725	010	0	1	01	01	H9725_010_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	010	0	1	01	01	H9725_010_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H9725	010	0	1	01	01	H9725_010_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	010	0	1	01	01	H9725_010_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	010	0	1	01	01	H9725_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											633.03	33						531.38	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	011	0	1	01	01	H9725_011_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00
H9725	011	0	1	01	01	H9725_011_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	011	0	1	01	01	H9725_011_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00
H9725	011	0	1	01	01	H9725_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	011	0	1	01	01	H9725_011_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					95.00	190.00	285.00											100.00	200.00	300.00				95.00	190.00	285.00				100.00				100.00			3.33	3.17		3.33	3.17	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	011	0	1	01	01	H9725_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											633.45	33						531.15	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	012	0	1	01	01	H9725_012_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	012	0	1	01	01	H9725_012_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	012	0	1	01	01	H9725_012_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	0.00	20.00		20.00
H9725	012	0	1	01	01	H9725_012_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	012	0	1	01	01	H9725_012_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	012	0	1	01	01	H9725_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											606.44	33						539.08	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9725	014	0	1	01	01	H9725_014_0	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
H9725	014	0	1	01	01	H9725_014_0	7			Preferred Generic	4	01	3	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
H9725	014	0	1	01	01	H9725_014_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	0.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	0.00	20.00		20.00
H9725	014	0	1	01	01	H9725_014_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	014	0	1	01	01	H9725_014_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9725	014	0	1	01	01	H9725_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											606.53	33						539.10	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
H9730	005	0	1	02	01	H9730_005_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	005	0	1	02	01	H9730_005_0	6			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H9730	005	0	1	02	01	H9730_005_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	005	0	1	02	01	H9730_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9730	005	0	1	02	01	H9730_005_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											72.26	50	50	50				72.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9730	005	0	1	02	01	H9730_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9730	005	0	1	02	01	H9730_005_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	005	0	1	02	01	H9730_005_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9730	007	0	1	01	01	H9730_007_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	007	0	1	01	01	H9730_007_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	007	0	1	01	01	H9730_007_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9730	007	0	1	01	01	H9730_007_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											59.60	50	50	50				59.60	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9730	007	0	1	01	01	H9730_007_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9730	007	0	1	01	01	H9730_007_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	007	0	1	01	01	H9730_007_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9730	009	0	1	01	01	H9730_009_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	009	0	1	01	01	H9730_009_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	009	0	1	01	01	H9730_009_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9730	009	0	1	01	01	H9730_009_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											70.61	50	50	50				70.61	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9730	009	0	1	01	01	H9730_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9730	009	0	1	01	01	H9730_009_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	009	0	1	01	01	H9730_009_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9730	010	0	1	01	01	H9730_010_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	010	0	1	01	01	H9730_010_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9730	010	0	1	01	01	H9730_010_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H9730	010	0	1	01	01	H9730_010_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.07	50	50	50				87.07	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9730	010	0	1	01	01	H9730_010_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9730	010	0	1	01	01	H9730_010_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	001	0	1	04	01	H9761_001_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	001	0	1	04	01	H9761_001_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	0.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	001	0	1	04	01	H9761_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9761	001	0	1	04	01	H9761_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.73	43	43	43				98.73	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9761	001	0	1	04	01	H9761_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9761	001	0	1	04	01	H9761_001_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	002	0	1	04	01	H9761_002_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	002	0	1	04	01	H9761_002_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					10.00	20.00	30.00											15.00	30.00	45.00				10.00	20.00	0.00				15.00				15.00			0.50	0.33		0.50	0.33	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	002	0	1	04	01	H9761_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9761	002	0	1	04	01	H9761_002_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											98.65	47	47	47				98.65	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9761	002	0	1	04	01	H9761_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9761	002	0	1	04	01	H9761_002_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	002	0	1	04	01	H9761_002_0	6			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9761	004	0	1	04	01	H9761_004_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	004	0	1	04	01	H9761_004_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	0.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9761	004	0	1	04	01	H9761_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9761	004	0	1	04	01	H9761_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.97	48	48	48				97.97	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9761	004	0	1	04	01	H9761_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9761	004	0	1	04	01	H9761_004_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9763	003	1	1	01	01	H9763_003_1	9			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H9763	003	1	1	01	01	H9763_003_1	9			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9763	003	1	1	01	01	H9763_003_1	9			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	25.00						25.00				10.00		10.00
H9763	003	1	1	01	01	H9763_003_1	9			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9763	003	1	1	01	01	H9763_003_1	9			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	45.00	90.00	135.00																					135.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	003	1	1	01	01	H9763_003_1	9			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	003	1	1	01	01	H9763_003_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H9763	003	2	1	01	01	H9763_003_2	8			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H9763	003	2	1	01	01	H9763_003_2	8			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9763	003	2	1	01	01	H9763_003_2	8			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	25.00						25.00				10.00		10.00
H9763	003	2	1	01	01	H9763_003_2	8			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9763	003	2	1	01	01	H9763_003_2	8			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	45.00	90.00	135.00																					135.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	003	2	1	01	01	H9763_003_2	8			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	003	2	1	01	01	H9763_003_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H9763	004	1	1	02	01	H9763_004_1	8			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H9763	004	1	1	02	01	H9763_004_1	8			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9763	004	1	1	02	01	H9763_004_1	8			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	25.00						25.00				10.00		10.00
H9763	004	1	1	02	01	H9763_004_1	8			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9763	004	1	1	02	01	H9763_004_1	8			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	45.00	90.00	135.00																					135.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	004	1	1	02	01	H9763_004_1	8			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	004	1	1	02	01	H9763_004_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H9763	004	2	1	02	01	H9763_004_2	9			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H9763	004	2	1	02	01	H9763_004_2	9			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9763	004	2	1	02	01	H9763_004_2	9			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	25.00						25.00				10.00		10.00
H9763	004	2	1	02	01	H9763_004_2	9			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9763	004	2	1	02	01	H9763_004_2	9			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	45.00	90.00	135.00																					135.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	004	2	1	02	01	H9763_004_2	9			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	004	2	1	02	01	H9763_004_2	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H9763	005	0	1	01	01	H9763_005_0	8			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													0.00	0.00	0.00						0.00				0.00		0.00
H9763	005	0	1	01	01	H9763_005_0	8			Preferred Generic	4	01	1	2	1	3	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9763	005	0	1	01	01	H9763_005_0	8			Generic	4	01	3	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													10.00	20.00	25.00						25.00				10.00		10.00
H9763	005	0	1	01	01	H9763_005_0	8			Generic	4	01	3	2	2	3	111		01	100		1	30	60	90				1	2			90				30		31	10.00	20.00	25.00																					25.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1		3															
H9763	005	0	1	01	01	H9763_005_0	8			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	45.00	90.00	135.00																					135.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	005	0	1	01	01	H9763_005_0	8			Non-Preferred Brand	4	10	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00						105.00				35.00		35.00
H9763	005	0	1	01	01	H9763_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00						35.00						35.00		35.00
H9808	004	0	1	04	01	H9808_004_0	10			Preferred Generic	4	01	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								5.00	10.00	10.00					0.00	0.00	0.00					0.00	0.00	0.00																	5.00			5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	004	0	1	04	01	H9808_004_0	10			Preferred Generic	4	01	3	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								5.00	10.00	10.00					0.00	0.00	0.00					0.00	0.00	0.00																	5.00			5.00			0.17	0.00	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H9808	004	0	1	04	01	H9808_004_0	10			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								15.00	30.00	30.00					5.00	10.00	10.00					5.00	10.00	10.00																	15.00			15.00			0.50	0.17	0.17			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	004	0	1	04	01	H9808_004_0	10			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	94.00					47.00	94.00	94.00					47.00	94.00	94.00																	47.00			47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	94.00	35.00	70.00	94.00	35.00	70.00	94.00				35.00		35.00
H9808	004	0	1	04	01	H9808_004_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	200.00					100.00	200.00	200.00					100.00	200.00	200.00																	100.00			100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	004	0	1	04	01	H9808_004_0	10			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											616.00	33	33	33				753.40	33	33	33				33	33	33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	005	0	1	04	01	H9808_005_0	10			Preferred Generic	4	01	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	005	0	1	04	01	H9808_005_0	10			Preferred Generic	4	01	3	2	1	3		111	10	111		1				30	60	100	1	2	30	60	100					29	31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																	0.00			0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H9808	005	0	1	04	01	H9808_005_0	10			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								12.00	24.00	24.00					0.00	0.00	0.00					0.00	0.00	0.00																	12.00			12.00			0.40	0.00	0.00			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	005	0	1	04	01	H9808_005_0	10			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								47.00	94.00	94.00					47.00	94.00	94.00					47.00	94.00	94.00																	47.00			47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	94.00	35.00	70.00	94.00	35.00	70.00	94.00				35.00		35.00
H9808	005	0	1	04	01	H9808_005_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								100.00	200.00	200.00					100.00	200.00	200.00					100.00	200.00	200.00																	100.00			100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9808	005	0	1	04	01	H9808_005_0	10			Specialty Tier	4	11	1	1	5	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											463.08	33	33	33				809.18	33	33	33				33	33	33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9827	001	0	1	01	01	H9827_001_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9827	001	0	1	01	01	H9827_001_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9827	001	0	1	01	01	H9827_001_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H9827	001	0	1	01	01	H9827_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9827	001	0	1	01	01	H9827_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9827	001	0	1	01	01	H9827_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9827	002	0	1	01	01	H9827_002_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9827	002	0	1	01	01	H9827_002_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9827	002	0	1	01	01	H9827_002_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H9827	002	0	1	01	01	H9827_002_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9827	002	0	1	01	01	H9827_002_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9827	002	0	1	01	01	H9827_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9827	004	0	1	01	01	H9827_004_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9827	004	0	1	01	01	H9827_004_0	9			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9827	004	0	1	01	01	H9827_004_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00
H9827	004	0	1	01	01	H9827_004_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9827	004	0	1	01	01	H9827_004_0	9			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	200.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00
H9827	004	0	1	01	01	H9827_004_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				950.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9834	001	0	1	01	01	H9834_001_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	001	0	1	01	01	H9834_001_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	001	0	1	01	01	H9834_001_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H9834	001	0	1	01	01	H9834_001_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	001	0	1	01	01	H9834_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	001	0	1	01	01	H9834_001_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	001	0	1	01	01	H9834_001_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9834	003	0	1	01	01	H9834_003_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	003	0	1	01	01	H9834_003_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	003	0	1	01	01	H9834_003_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H9834	003	0	1	01	01	H9834_003_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	003	0	1	01	01	H9834_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	003	0	1	01	01	H9834_003_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	003	0	1	01	01	H9834_003_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9834	006	0	1	01	01	H9834_006_0	4			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	5.00	10.00	15.00																					12.50																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	006	0	1	01	01	H9834_006_0	4			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					38.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	006	0	1	01	01	H9834_006_0	4			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					117.50																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00						105.00				35.00		35.00
H9834	006	0	1	01	01	H9834_006_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				1	2			90				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	006	0	1	01	01	H9834_006_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	006	0	1	01	01	H9834_006_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	1	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9834	006	0	1	01	01	H9834_006_0	4			Vaccines ($0 cost sharing)	4	10	1	2	6	3	010		01	000		1	30														30		31	0.00																																							0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9861	001	0	1	02	01	H9861_001_0	11			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9861	001	0	1	02	01	H9861_001_0	11			Preferred Generic	4	01	1	1	1	3	110		01	110		1	30		100				2	2	30		100				30		31				1.54	0		0																		0		0															0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9861	001	0	1	02	01	H9861_001_0	11			Generic	4	01	1	2	2	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9861	001	0	1	02	01	H9861_001_0	11			Generic	4	01	1	1	2	3	110		01	110		1	30		100				2	2	30		100				30		31				4.28	0		0																		0		0															0			0								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9861	001	0	1	02	01	H9861_001_0	11			Preferred Brand	4	10	1	2	3	1	110		01	110		1	30		100				2	2	30		100				30		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		30.00				10.00		10.00
H9861	001	0	1	02	01	H9861_001_0	11			Non-Preferred Drug	4	10	1	2	4	1	110		01	110		1	30		100				2	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				10.00		30.00				10.00		10.00
H9861	001	0	1	02	01	H9861_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				704.06	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9861	003	0	1	01	01	H9861_003_0	11		N	Preferred Generic	4	01	1	1	1	1	110		01	110		1	30		100				1	2	30		100				30		31				4.49	20		20																		20		20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9861	003	0	1	01	01	H9861_003_0	11		N	Generic	4	01	1	1	2	1	110		01	110		1	30		100				1	2	30		100				30		31				4.49	20		20																		20		20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9861	003	0	1	01	01	H9861_003_0	11		N	Preferred Brand	4	10	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				72.62	20		20																		20		20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H9861	003	0	1	01	01	H9861_003_0	11		N	Non-Preferred Drug	4	10	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				72.62	20		20																		20		20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
H9861	003	0	1	01	01	H9861_003_0	11		N	Specialty Tier	4	01	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9869	001	0	1	48	05	H9869_001_0	5			Generic Drugs	4	01		2	1	1	110		01	101		1	30		90				2	2		60	90				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9869	001	0	1	48	05	H9869_001_0	5			Brand Drugs	4	10		2	2	1	110		01	101		1	30		90				2	2		60	90				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9869	001	0	1	48	05	H9869_001_0	5			Non-Medicare Rx/OTC Drugs	4	11		2	3	1	110		01	101		1	30		90				2	2		60	90				30		31																																														0.00						0.00	Generic Drugs, Brand Drugs, Non-Medicare Rx/OTC Drugs	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00																		
H9876	001	0	1	04	01	H9876_001_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	001	0	1	04	01	H9876_001_0	9			Preferred Generic	4	01	1	2	1	3	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9876	001	0	1	04	01	H9876_001_0	9			Generic	4	01	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	001	0	1	04	01	H9876_001_0	9			Preferred Brand	4	10	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	141.00																			47.00	94.00	118.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9876	001	0	1	04	01	H9876_001_0	9			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	300.00																			100.00	200.00	250.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	001	0	1	04	01	H9876_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	002	0	1	04	01	H9876_002_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	002	0	1	04	01	H9876_002_0	9			Preferred Generic	4	01	1	2	1	3	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier										1																	
H9876	002	0	1	04	01	H9876_002_0	9			Generic	4	01	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	002	0	1	04	01	H9876_002_0	9			Preferred Brand	4	10	1	2	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9876	002	0	1	04	01	H9876_002_0	9			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9876	002	0	1	04	01	H9876_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9884	001	0	1	04	01	H9884_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	001	0	1	04	01	H9884_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	001	0	1	04	01	H9884_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	001	0	1	04	01	H9884_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9884	001	0	1	04	01	H9884_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	001	0	1	04	01	H9884_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	001	0	1	04	01	H9884_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	003	0	1	04	01	H9884_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	003	0	1	04	01	H9884_003_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	003	0	1	04	01	H9884_003_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	003	0	1	04	01	H9884_003_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9884	003	0	1	04	01	H9884_003_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	003	0	1	04	01	H9884_003_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	003	0	1	04	01	H9884_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	004	0	1	04	01	H9884_004_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	004	0	1	04	01	H9884_004_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	004	0	1	04	01	H9884_004_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	004	0	1	04	01	H9884_004_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9884	004	0	1	04	01	H9884_004_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	004	0	1	04	01	H9884_004_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	004	0	1	04	01	H9884_004_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	005	0	1	04	01	H9884_005_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	005	0	1	04	01	H9884_005_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	005	0	1	04	01	H9884_005_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	005	0	1	04	01	H9884_005_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9884	005	0	1	04	01	H9884_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	005	0	1	04	01	H9884_005_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	005	0	1	04	01	H9884_005_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	006	0	1	04	01	H9884_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	006	0	1	04	01	H9884_006_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	006	0	1	04	01	H9884_006_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	006	0	1	04	01	H9884_006_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9884	006	0	1	04	01	H9884_006_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	006	0	1	04	01	H9884_006_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	006	0	1	04	01	H9884_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	007	0	1	04	01	H9884_007_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	007	0	1	04	01	H9884_007_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	007	0	1	04	01	H9884_007_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	007	0	1	04	01	H9884_007_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9884	007	0	1	04	01	H9884_007_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	007	0	1	04	01	H9884_007_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	007	0	1	04	01	H9884_007_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	008	0	1	04	01	H9884_008_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	008	0	1	04	01	H9884_008_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	008	0	1	04	01	H9884_008_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9884	008	0	1	04	01	H9884_008_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9884	008	0	1	04	01	H9884_008_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	008	0	1	04	01	H9884_008_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	008	0	1	04	01	H9884_008_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	011	0	1	04	01	H9884_011_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	011	0	1	04	01	H9884_011_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	011	0	1	04	01	H9884_011_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9884	011	0	1	04	01	H9884_011_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9884	011	0	1	04	01	H9884_011_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	011	0	1	04	01	H9884_011_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	011	0	1	04	01	H9884_011_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	012	0	1	04	01	H9884_012_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	012	0	1	04	01	H9884_012_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	012	0	1	04	01	H9884_012_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	012	0	1	04	01	H9884_012_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9884	012	0	1	04	01	H9884_012_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	012	0	1	04	01	H9884_012_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	012	0	1	04	01	H9884_012_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9884	013	0	1	04	01	H9884_013_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9884	013	0	1	04	01	H9884_013_0	10			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9884	013	0	1	04	01	H9884_013_0	10			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00	10.00	15.00				5.00	10.00	12.50				5.00		5.00
H9884	013	0	1	04	01	H9884_013_0	10			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	2															
H9884	013	0	1	04	01	H9884_013_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	013	0	1	04	01	H9884_013_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9884	013	0	1	04	01	H9884_013_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9888	001	0	1	04	01	H9888_001_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9888	001	0	1	04	01	H9888_001_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9888	001	0	1	04	01	H9888_001_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9888	001	0	1	04	01	H9888_001_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9888	001	0	1	04	01	H9888_001_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9888	001	0	1	04	01	H9888_001_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9888	001	0	1	04	01	H9888_001_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9888	002	0	1	04	01	H9888_002_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9888	002	0	1	04	01	H9888_002_0	11			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2																
H9888	002	0	1	04	01	H9888_002_0	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9888	002	0	1	04	01	H9888_002_0	11			Generic	4	11	3	2	2	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2	2	3															
H9888	002	0	1	04	01	H9888_002_0	11			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9888	002	0	1	04	01	H9888_002_0	11			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9888	002	0	1	04	01	H9888_002_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
H9900	001	0	1	01	01	H9900_001_0	16			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	001	0	1	01	01	H9900_001_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	001	0	1	01	01	H9900_001_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9900	001	0	1	01	01	H9900_001_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											95.52	50	50	50				95.52	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9900	001	0	1	01	01	H9900_001_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9900	001	0	1	01	01	H9900_001_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	004	0	1	01	01	H9900_004_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	004	0	1	01	01	H9900_004_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H9900	004	0	1	01	01	H9900_004_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					1.00	2.00	3.00											2.00	4.00	6.00				1.00	2.00	0.00				2.00				2.00			0.07	0.03		0.07	0.03	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	004	0	1	01	01	H9900_004_0	7			Generic	4	11	1	2	2	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								2.00	4.00	6.00					1.00	2.00	3.00											2.00	4.00	6.00				1.00	2.00	0.00				2.00				2.00			0.07	0.03		0.07	0.03	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9900	004	0	1	01	01	H9900_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9900	004	0	1	01	01	H9900_004_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											88.49	50	50	50				88.49	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9900	004	0	1	01	01	H9900_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9900	004	0	1	01	01	H9900_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	004	0	1	01	01	H9900_004_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9900	005	0	1	01	01	H9900_005_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	005	0	1	01	01	H9900_005_0	7			Preferred Generic	4	11	3	2	1	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
H9900	005	0	1	01	01	H9900_005_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	005	0	1	01	01	H9900_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9900	005	0	1	01	01	H9900_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											87.76	50	50	50				87.76	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9900	005	0	1	01	01	H9900_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9900	005	0	1	01	01	H9900_005_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	005	0	1	01	01	H9900_005_0	7			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
H9900	006	0	1	01	01	H9900_006_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	006	0	1	01	01	H9900_006_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	006	0	1	01	01	H9900_006_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H9900	006	0	1	01	01	H9900_006_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											99.30	44	44	44				99.30	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9900	006	0	1	01	01	H9900_006_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9900	006	0	1	01	01	H9900_006_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	007	0	1	01	01	H9900_007_0	6			Preferred Generic	3	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00											19.00	38.00	57.00				0.00	0.00	0.00				19.00				19.00			0.63	0.00		0.63	0.00	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	007	0	1	01	01	H9900_007_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					20.00	40.00	60.00											20.00	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9900	007	0	1	01	01	H9900_007_0	6			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	94.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00	35.00		35.00
H9900	007	0	1	01	01	H9900_007_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											97.86	44	44	44				97.86	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9900	007	0	1	01	01	H9900_007_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9900	007	0	1	01	01	H9900_007_0	6			Select Care Drugs	3	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9904	001	0	1	04	01	H9904_001_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9904	001	0	1	04	01	H9904_001_0	6			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
H9904	001	0	1	04	01	H9904_001_0	6			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	12.00																			6.00	12.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9904	001	0	1	04	01	H9904_001_0	6			Generic	4	11	3	2	2	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	12.00																			6.00	12.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
H9904	001	0	1	04	01	H9904_001_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	42.00	84.00	84.00																			42.00	84.00	84.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00
H9904	001	0	1	04	01	H9904_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	190.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9904	001	0	1	04	01	H9904_001_0	6			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				646.41	29	29	29																		29	29	29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
H9907	001	0	1	04	01	H9907_001_0	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					0.00	0.00	0.00																14.00				0.00			0.47	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													14.00	28.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00				14.00		0.00
H9907	001	0	1	04	01	H9907_001_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00
H9907	001	0	1	04	01	H9907_001_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
H9907	001	0	1	04	01	H9907_001_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
H9907	001	0	1	04	01	H9907_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9907	001	0	1	04	01	H9907_001_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	1		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)																											
H9907	001	0	1	04	01	H9907_001_0	7			Vaccines ($0 cost sharing)	4	11	1	2	6	3		111	01	000		1				30	60	90	1	2							30		31								0.00	0.00	0.00					0.00	0.00	0.00																							0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines ($0 cost sharing)										1																	
H9917	001	0	1	01	01	H9917_001_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	001	0	1	01	01	H9917_001_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	001	0	1	01	01	H9917_001_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9917	001	0	1	01	01	H9917_001_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	001	0	1	01	01	H9917_001_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	002	0	1	01	01	H9917_002_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	002	0	1	01	01	H9917_002_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	002	0	1	01	01	H9917_002_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9917	002	0	1	01	01	H9917_002_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	002	0	1	01	01	H9917_002_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	003	0	1	01	01	H9917_003_0	8			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	2.00	4.00	6.00																			2.00	4.00	6.00																	2.00			2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H9917	003	0	1	01	01	H9917_003_0	8			Generic	4	11	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H9917	003	0	1	01	01	H9917_003_0	8			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9917	003	0	1	01	01	H9917_003_0	8			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H9917	003	0	1	01	01	H9917_003_0	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H9917	003	0	1	01	01	H9917_003_0	8			Select Care Drugs	4	11	1	2	6	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																											
H9917	004	0	1	01	01	H9917_004_0	10			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	004	0	1	01	01	H9917_004_0	10			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	004	0	1	01	01	H9917_004_0	10			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9917	004	0	1	01	01	H9917_004_0	10			Non-Preferred Brand	4	10	1	2	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	95.00	190.00	285.00																			95.00	190.00	285.00																	95.00			95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9917	004	0	1	01	01	H9917_004_0	10			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier																											
H9943	001	0	1	02	01	H9943_001_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	001	0	1	02	01	H9943_001_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	001	0	1	02	01	H9943_001_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	001	0	1	02	01	H9943_001_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	001	0	1	02	01	H9943_001_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	001	0	1	02	01	H9943_001_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				778.33	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	001	0	1	02	01	H9943_001_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	001	0	1	02	01	H9943_001_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	002	0	1	02	01	H9943_002_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	002	0	1	02	01	H9943_002_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	002	0	1	02	01	H9943_002_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	002	0	1	02	01	H9943_002_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	002	0	1	02	01	H9943_002_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	002	0	1	02	01	H9943_002_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				771.64	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	002	0	1	02	01	H9943_002_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	002	0	1	02	01	H9943_002_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	003	0	1	01	01	H9943_003_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	003	0	1	01	01	H9943_003_0	14			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	003	0	1	01	01	H9943_003_0	14			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	003	0	1	01	01	H9943_003_0	14			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	003	0	1	01	01	H9943_003_0	14			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	003	0	1	01	01	H9943_003_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				798.86	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	003	0	1	01	01	H9943_003_0	14			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	003	0	1	01	01	H9943_003_0	14			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	004	0	1	01	01	H9943_004_0	15		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.54	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	004	0	1	01	01	H9943_004_0	15		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.10	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	004	0	1	01	01	H9943_004_0	15		N	Preferred Brand	4	11	3	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.58	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	004	0	1	01	01	H9943_004_0	15		N	Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.41	37	37	37																		37	37	37															37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	004	0	1	01	01	H9943_004_0	15		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				553.28	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	004	0	1	01	01	H9943_004_0	15		N	Select Care Drugs	4	01	1	1	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.03	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	005	0	1	02	01	H9943_005_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	005	0	1	02	01	H9943_005_0	13			Preferred Generic	4	11	1	2	1	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9943	005	0	1	02	01	H9943_005_0	13			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
H9943	005	0	1	02	01	H9943_005_0	13			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	005	0	1	02	01	H9943_005_0	13			Non-Preferred Drug	4	11	3	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
H9943	005	0	1	02	01	H9943_005_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				511.32	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	005	0	1	02	01	H9943_005_0	13			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9943	005	0	1	02	01	H9943_005_0	13			Select Care Drugs	4	01	1	2	6	3	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
H9955	002	0	1	01	01	H9955_002_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	3.00	6.00	9.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	002	0	1	01	01	H9955_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	12.00	24.00	36.00																			12.00	24.00	24.00																12.00				12.00		0.39			0.39			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	002	0	1	01	01	H9955_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H9955	002	0	1	01	01	H9955_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	002	0	1	01	01	H9955_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1112.52	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H9955	002	0	1	01	01	H9955_002_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	004	0	1	01	01	H9955_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	15.00	30.00	45.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	004	0	1	01	01	H9955_004_0	5			Generic	4	11	1	2	2	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	20.00	40.00	60.00																			20.00	40.00	40.00																20.00				20.00		0.65			0.65			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	004	0	1	01	01	H9955_004_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00
H9955	004	0	1	01	01	H9955_004_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.23			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9955	004	0	1	01	01	H9955_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1032.62	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
H9955	004	0	1	01	01	H9955_004_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	31	60	90				1	2	31	60	90				31		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9976	002	0	1	04	01	H9976_002_0	17			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9976	002	0	1	04	01	H9976_002_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	0.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9976	002	0	1	04	01	H9976_002_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	84.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00	35.00		35.00
H9976	002	0	1	04	01	H9976_002_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											93.77	50	50	50				93.77	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
H9976	002	0	1	04	01	H9976_002_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
H9976	002	0	1	04	01	H9976_002_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
H9976	002	0	1	04	01	H9976_002_0	17			Select Care Drugs	4	11	1	2	6	3		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										2	2																
R0110	003	0	1	31	11	R0110_003_0	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									15.00		45.00				0.00		0.00				0.00				0.00		0.00				0.50	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				15.00		45.00	0.00		0.00	0.00		0.00
R0110	003	0	1	31	11	R0110_003_0	9			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
R0110	003	0	1	31	11	R0110_003_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R0110	003	0	1	31	11	R0110_003_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R0110	003	0	1	31	11	R0110_003_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R0759	001	0	1	31	11	R0759_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R0759	001	0	1	31	11	R0759_001_0	4			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R0759	001	0	1	31	11	R0759_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R0759	001	0	1	31	11	R0759_001_0	4			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.26						0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R0759	001	0	1	31	11	R0759_001_0	4			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R0759	001	0	1	31	11	R0759_001_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R0759	001	0	1	31	11	R0759_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				268.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R0865	003	0	1	31	11	R0865_003_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
R0865	003	0	1	31	11	R0865_003_0	7			Preferred Generic	4	11	3	2	1	3	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
R0865	003	0	1	31	11	R0865_003_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00
R0865	003	0	1	31	11	R0865_003_0	7			Generic	4	11	3	2	2	3	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
R0865	003	0	1	31	11	R0865_003_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R0865	003	0	1	31	11	R0865_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R0865	003	0	1	31	11	R0865_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R0923	002	0	1	31	11	R0923_002_0	18			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
R0923	002	0	1	31	11	R0923_002_0	18			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
R0923	002	0	1	31	11	R0923_002_0	18			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R0923	002	0	1	31	11	R0923_002_0	18			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R0923	002	0	1	31	11	R0923_002_0	18			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R1390	002	0	1	31	11	R1390_002_0	7			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	8.00		24.00																									10.00		30.00				8.00		0.00				8.00				8.00		0.27				0.33	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00		24.00				10.00		30.00	8.00		0.00	8.00		8.00
R1390	002	0	1	31	11	R1390_002_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	18.00		54.00																									20.00		60.00				18.00		0.00				18.00				18.00		0.60				0.67	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				20.00		60.00	18.00		0.00	18.00		18.00
R1390	002	0	1	31	11	R1390_002_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R1390	002	0	1	31	11	R1390_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R1390	002	0	1	31	11	R1390_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R1532	002	0	1	31	11	R1532_002_0	7			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	19.00		57.00																									19.00		57.00				19.00		0.00				19.00				19.00		0.63				0.63	0.63	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00		57.00				19.00		57.00	19.00		0.00	19.00		19.00
R1532	002	0	1	31	11	R1532_002_0	7			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
R1532	002	0	1	31	11	R1532_002_0	7			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				47.00	18		18																								25		25				18		18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R1532	002	0	1	31	11	R1532_002_0	7			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				66.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R1532	002	0	1	31	11	R1532_002_0	7			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R2604	001	0	1	31	11	R2604_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R2604	001	0	1	31	11	R2604_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R2604	001	0	1	31	11	R2604_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		35.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R2604	001	0	1	31	11	R2604_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		35.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R2604	001	0	1	31	11	R2604_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R2604	001	0	1	31	11	R2604_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R2604	001	0	1	31	11	R2604_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				304.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R2604	003	0	1	31	11	R2604_003_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R2604	003	0	1	31	11	R2604_003_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R2604	003	0	1	31	11	R2604_003_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R2604	003	0	1	31	11	R2604_003_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R2604	003	0	1	31	11	R2604_003_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
R2604	003	0	1	31	11	R2604_003_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R2604	003	0	1	31	11	R2604_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				461.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R3332	001	0	1	31	11	R3332_001_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R3332	001	0	1	31	11	R3332_001_0	9			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
R3332	001	0	1	31	11	R3332_001_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R3332	001	0	1	31	11	R3332_001_0	9			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
R3332	001	0	1	31	11	R3332_001_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	2	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00				35.00		105.00				35.00		35.00
R3332	001	0	1	31	11	R3332_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1758.73	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00						35.00						35.00		35.00
R3332	001	0	1	31	11	R3332_001_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R3332	001	0	1	31	11	R3332_001_0	9			Select Care Drugs	4	01	1	2	6	3	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
R3392	002	0	1	31	11	R3392_002_0	9			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	7.00		21.00																									10.00		30.00				7.00		0.00				7.00				7.00		0.23				0.33	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00		21.00				10.00		30.00	7.00		0.00	7.00		7.00
R3392	002	0	1	31	11	R3392_002_0	9			Generic	4	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	17.00		51.00																									20.00		60.00				17.00		0.00				17.00				17.00		0.57				0.67	0.57	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00				20.00		60.00	17.00		0.00	17.00		17.00
R3392	002	0	1	31	11	R3392_002_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R3392	002	0	1	31	11	R3392_002_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R3392	002	0	1	31	11	R3392_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R3392	004	0	1	31	11	R3392_004_0	9			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	4.00		12.00																									10.00		30.00				4.00		0.00				4.00				4.00		0.13				0.33	0.13	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00		12.00				10.00		30.00	4.00		0.00	4.00		4.00
R3392	004	0	1	31	11	R3392_004_0	9			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	12.00		36.00																									20.00		60.00				12.00		0.00				12.00				12.00		0.40				0.67	0.40	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00		36.00				20.00		60.00	12.00		0.00	12.00		12.00
R3392	004	0	1	31	11	R3392_004_0	9			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R3392	004	0	1	31	11	R3392_004_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R3392	004	0	1	31	11	R3392_004_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R3444	009	0	1	31	11	R3444_009_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		10.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R3444	009	0	1	31	11	R3444_009_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		10.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R3444	009	0	1	31	11	R3444_009_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	15.00		37.50																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R3444	009	0	1	31	11	R3444_009_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	15.00		37.50																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R3444	009	0	1	31	11	R3444_009_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
R3444	009	0	1	31	11	R3444_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R3444	009	0	1	31	11	R3444_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				229.00	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R3444	012	0	1	31	11	R3444_012_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		10.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R3444	012	0	1	31	11	R3444_012_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		10.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R3444	012	0	1	31	11	R3444_012_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	15.00		37.50																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R3444	012	0	1	31	11	R3444_012_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	15.00		37.50																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R3444	012	0	1	31	11	R3444_012_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R3444	012	0	1	31	11	R3444_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R3444	012	0	1	31	11	R3444_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				234.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R4182	003	0	1	31	11	R4182_003_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
R4182	003	0	1	31	11	R4182_003_0	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R4182	003	0	1	31	11	R4182_003_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00
R4182	003	0	1	31	11	R4182_003_0	8			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	10.00		30.00																									20.00		60.00				10.00		0.00				10.00				10.00		0.33				0.67	0.33	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R4182	003	0	1	31	11	R4182_003_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R4182	003	0	1	31	11	R4182_003_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R4182	003	0	1	31	11	R4182_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R4182	004	0	1	31	11	R4182_004_0	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
R4182	004	0	1	31	11	R4182_004_0	8			Preferred Generic	4	11	1	2	1	3	110		01		110	1	30		100				1	2				30		100	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R4182	004	0	1	31	11	R4182_004_0	8			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	13.00		39.00																									20.00		60.00				13.00		0.00				13.00				13.00		0.43				0.67	0.43	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00		39.00				20.00		60.00	13.00		0.00	13.00		13.00
R4182	004	0	1	31	11	R4182_004_0	8			Generic	4	11	1	2	2	3	110		01		110	1	30		100				2	2				30		100	30		31	13.00		39.00																									20.00		60.00				13.00		0.00				13.00				13.00		0.43				0.67	0.43	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R4182	004	0	1	31	11	R4182_004_0	8			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R4182	004	0	1	31	11	R4182_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	99.00		297.00																									100.00		300.00				99.00		287.00				99.00				99.00		3.30				3.33	3.30	3.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R4182	004	0	1	31	11	R4182_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R4487	001	0	1	31	11	R4487_001_0	12			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								11.00	22.00	33.00					6.00	12.00	18.00					0.00	0.00	0.00																11.00				11.00			0.37	0.20	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R4487	001	0	1	31	11	R4487_001_0	12			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R4487	001	0	1	31	11	R4487_001_0	12			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					37.00	74.00	111.00					37.00	74.00	74.00																47.00				47.00			1.57	1.23	1.23			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
R4487	001	0	1	31	11	R4487_001_0	12			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.49	47	47	47				45.50	46	46	46				46	46	46															47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R4487	001	0	1	31	11	R4487_001_0	12			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R4487	001	0	1	31	11	R4487_001_0	12			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R4487	001	0	1	31	11	R4487_001_0	12			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
R4845	002	0	1	31	11	R4845_002_0	5			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	19.00		57.00																									19.00		57.00				19.00		0.00				19.00				19.00		0.63				0.63	0.63	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00		57.00				19.00		57.00	19.00		0.00	19.00		19.00
R4845	002	0	1	31	11	R4845_002_0	5			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
R4845	002	0	1	31	11	R4845_002_0	5			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				49.00	21		21																								25		25				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R4845	002	0	1	31	11	R4845_002_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R4845	002	0	1	31	11	R4845_002_0	5			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R5329	001	0	1	31	11	R5329_001_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5329	001	0	1	31	11	R5329_001_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R5329	001	0	1	31	11	R5329_001_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5329	001	0	1	31	11	R5329_001_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R5329	001	0	1	31	11	R5329_001_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5329	001	0	1	31	11	R5329_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5329	001	0	1	31	11	R5329_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				275.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	001	0	1	31	11	R5342_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	001	0	1	31	11	R5342_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R5342	001	0	1	31	11	R5342_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	001	0	1	31	11	R5342_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R5342	001	0	1	31	11	R5342_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5342	001	0	1	31	11	R5342_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5342	001	0	1	31	11	R5342_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				288.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	005	0	1	31	11	R5342_005_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	005	0	1	31	11	R5342_005_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R5342	005	0	1	31	11	R5342_005_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	005	0	1	31	11	R5342_005_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	14.00		28.00																											42.00						0.00				14.00				14.00		0.46						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R5342	005	0	1	31	11	R5342_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5342	005	0	1	31	11	R5342_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5342	005	0	1	31	11	R5342_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				298.00	30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	006	0	1	31	11	R5342_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	006	0	1	31	11	R5342_006_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R5342	006	0	1	31	11	R5342_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5342	006	0	1	31	11	R5342_006_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R5342	006	0	1	31	11	R5342_006_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5342	006	0	1	31	11	R5342_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R5342	006	0	1	31	11	R5342_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				531.00	33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R5361	002	0	1	31	11	R5361_002_0	5			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00
R5361	002	0	1	31	11	R5361_002_0	5			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
R5361	002	0	1	31	11	R5361_002_0	5			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				60.00	24		24																								25		25				24		24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R5361	002	0	1	31	11	R5361_002_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				54.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R5361	002	0	1	31	11	R5361_002_0	5			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R5826	005	0	1	31	11	R5826_005_0	7			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									10.00		30.00				5.00		0.00				5.00				5.00		0.17				0.33	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				10.00		30.00	5.00		0.00	5.00		5.00
R5826	005	0	1	31	11	R5826_005_0	7			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	15.00		45.00																									20.00		60.00				15.00		0.00				15.00				15.00		0.50				0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00				20.00		60.00	15.00		0.00	15.00		15.00
R5826	005	0	1	31	11	R5826_005_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	45.00		135.00																									47.00		141.00				45.00		125.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R5826	005	0	1	31	11	R5826_005_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	95.00		285.00																									100.00		300.00				95.00		275.00				95.00				95.00		3.17				3.33	3.17	3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R5826	005	0	1	31	11	R5826_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R5826	074	0	1	31	11	R5826_074_0	6			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	6.00		18.00																									10.00		30.00				6.00		0.00				6.00				6.00		0.20				0.33	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00		18.00				10.00		30.00	6.00		0.00	6.00		6.00
R5826	074	0	1	31	11	R5826_074_0	6			Generic	4	11	3	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
R5826	074	0	1	31	11	R5826_074_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		90				2	2				30		90	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R5826	074	0	1	31	11	R5826_074_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		90				2	2				30		90	30		31	100.00		300.00																									100.00		300.00				100.00		290.00				100.00				100.00		3.33				3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R5826	074	0	1	31	11	R5826_074_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R5941	014	0	1	31	11	R5941_014_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								11.00	22.00	33.00					6.00	12.00	18.00					0.00	0.00	0.00																11.00				11.00			0.37	0.20	0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R5941	014	0	1	31	11	R5941_014_0	8			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					15.00	30.00	45.00					0.00	0.00	0.00																20.00				20.00			0.67	0.50	0.00			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R5941	014	0	1	31	11	R5941_014_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
R5941	014	0	1	31	11	R5941_014_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.79	42	42	42				51.53	41	41	41				41	41	41															42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R5941	014	0	1	31	11	R5941_014_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												32							32						32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R5941	014	0	1	31	11	R5941_014_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
R5941	014	0	1	31	11	R5941_014_0	8			Select Care Drugs	4	01	1	2	6	3		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
R6694	003	0	1	31	11	R6694_003_0	8			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	003	0	1	31	11	R6694_003_0	8			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
R6694	003	0	1	31	11	R6694_003_0	8			Generic	4	01	3	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	003	0	1	31	11	R6694_003_0	8			Generic	4	01	3	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
R6694	003	0	1	31	11	R6694_003_0	8			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
R6694	003	0	1	31	11	R6694_003_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
R6694	003	0	1	31	11	R6694_003_0	8			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											932.55	33						513.04	33												33						33						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
R6694	005	0	1	31	11	R6694_005_0	7			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	005	0	1	31	11	R6694_005_0	7			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R6694	005	0	1	31	11	R6694_005_0	7			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	005	0	1	31	11	R6694_005_0	7			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R6694	005	0	1	31	11	R6694_005_0	7			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.03	25	25	25				71.92	20	20	20										25	25	25				20	20	20				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
R6694	005	0	1	31	11	R6694_005_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											90.29	40	40	40				75.94	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	005	0	1	31	11	R6694_005_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											861.88	29						566.50	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
R6694	006	0	1	31	11	R6694_006_0	9			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	006	0	1	31	11	R6694_006_0	9			Preferred Generic	4	01	1	2	1	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R6694	006	0	1	31	11	R6694_006_0	9			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	006	0	1	31	11	R6694_006_0	9			Generic	4	01	1	2	2	3		111	10		111	1				30	60	100	1	2				30	60	100		10	31								10.00	20.00	30.00					5.00	10.00	10.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R6694	006	0	1	31	11	R6694_006_0	9			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
R6694	006	0	1	31	11	R6694_006_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00					100.00			100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6694	006	0	1	31	11	R6694_006_0	9			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											786.30	28						547.51	28												28						28						28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
R6801	009	0	1	31	11	R6801_009_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6801	009	0	1	31	11	R6801_009_0	5			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R6801	009	0	1	31	11	R6801_009_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6801	009	0	1	31	11	R6801_009_0	5			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R6801	009	0	1	31	11	R6801_009_0	5			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													25.00		75.00						75.00			65.00	25.00		25.00
R6801	009	0	1	31	11	R6801_009_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R6801	009	0	1	31	11	R6801_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				218.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6801	012	0	1	31	11	R6801_012_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6801	012	0	1	31	11	R6801_012_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	4.00		12.00																											12.00						0.00				4.00				4.00		0.13						0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R6801	012	0	1	31	11	R6801_012_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R6801	012	0	1	31	11	R6801_012_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R6801	012	0	1	31	11	R6801_012_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R6801	012	0	1	31	11	R6801_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R6801	012	0	1	31	11	R6801_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				237.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R7220	002	0	1	31	11	R7220_002_0	4			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
R7220	002	0	1	31	11	R7220_002_0	4			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	19.00		57.00																									20.00		60.00				19.00		0.00				19.00				19.00		0.63				0.67	0.63	0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													19.00		57.00				20.00		60.00	19.00		0.00	19.00		19.00
R7220	002	0	1	31	11	R7220_002_0	4			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				51.00	22		22																								25		25				22		22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R7220	002	0	1	31	11	R7220_002_0	4			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				62.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R7220	002	0	1	31	11	R7220_002_0	4			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R7315	002	0	1	31	11	R7315_002_0	6			Preferred Generic	3	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	18.00		54.00																									19.00		57.00				18.00		0.00				18.00				18.00		0.60				0.63	0.60	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													18.00		54.00				19.00		57.00	18.00		0.00	18.00		18.00
R7315	002	0	1	31	11	R7315_002_0	6			Generic	3	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	20.00		60.00																									20.00		60.00				20.00		0.00				20.00				20.00		0.67				0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00				20.00		60.00	20.00		0.00	20.00		20.00
R7315	002	0	1	31	11	R7315_002_0	6			Preferred Brand	3	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				47.00	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R7315	002	0	1	31	11	R7315_002_0	6			Non-Preferred Drug	3	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				85.00	33		33																								33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
R7315	002	0	1	31	11	R7315_002_0	6			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
R7444	001	0	1	31	11	R7444_001_0	6			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R7444	001	0	1	31	11	R7444_001_0	6			Preferred Generic	4	01	1	2	1	3	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
R7444	001	0	1	31	11	R7444_001_0	6			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
R7444	001	0	1	31	11	R7444_001_0	6			Generic	4	01	3	2	2	3	110		01		100	1	30		100				2	2						100	30		31	12.00		24.00																											36.00						0.00				12.00				12.00		0.40						0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
R7444	001	0	1	31	11	R7444_001_0	6			Preferred Brand	4	11	1	2	3	1	110		01		100	1	30		100				2	2						100	30		31	47.00		141.00																											141.00						131.00				47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R7444	001	0	1	31	11	R7444_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01		100	1	30		100				2	2						100	30		31	100.00		300.00																											300.00						290.00				100.00				100.00		3.33						3.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00			95.00	35.00		35.00
R7444	001	0	1	31	11	R7444_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				282.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S1030	001	0		29	10	S1030_001_0	1			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								9.00		27.00					2.00		4.00											9.00		18.00				2.00		4.00				9.00				9.00			0.30	0.06		0.30	0.06	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00	2.00		4.00	9.00		18.00	2.00		4.00	9.00		9.00
S1030	001	0		29	10	S1030_001_0	1			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		51.00					10.00		20.00											17.00		34.00				10.00		20.00				17.00				17.00			0.56	0.33		0.56	0.33	0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00		51.00	10.00		20.00	17.00		34.00	10.00		20.00	17.00		17.00
S1030	001	0		29	10	S1030_001_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
S1030	001	0		29	10	S1030_001_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											99.09	34		34				75.57	29		29										34		34				29		29			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
S1030	001	0		29	10	S1030_001_0	1			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	33		33				1.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S1030	006	0		29	10	S1030_006_0	1			Preferred Generic	2	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00				0.00		0.00
S1030	006	0		29	10	S1030_006_0	1			Generic	2	01	1	2	2	1	110		01	110		1	30		90				1	2	30		90				30		31	14.00		42.00																			14.00		28.00																14.00				14.00		0.47			0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													14.00		42.00				14.00		28.00				14.00		14.00
S1030	006	0		29	10	S1030_006_0	1			Preferred Brand	2	11	1	2	3	1	110		01	110		1	30		90				1	2	30		90				30		31	47.00		141.00																			47.00		94.00																47.00				47.00		1.56			1.56			1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
S1030	006	0		29	10	S1030_006_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01	110		1	30		90				1	2	30		90				30		31				98.80	46		46																		46		46															46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		70.00				35.00		35.00
S1030	006	0		29	10	S1030_006_0	1			Specialty Tier	2	11	1	1	5	1	110		01	110		1	30		90				1	2	30		90				30		31				1.00	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S1030	010	0		29	10	S1030_010_0	1			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								9.00		27.00					2.00		4.00											9.00		18.00				2.00		4.00				9.00				9.00			0.30	0.06		0.30	0.07	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00		27.00	2.00		4.00	9.00		18.00	2.00		4.00	9.00		9.00
S1030	010	0		29	10	S1030_010_0	1			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								15.00		45.00					8.00		16.00											15.00		30.00				8.00		16.00				15.00				15.00			0.50	0.26		0.50	0.26	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00		45.00	8.00		16.00	15.00		30.00	8.00		16.00	15.00		15.00
S1030	010	0		29	10	S1030_010_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	1	2				30		90	30		31								47.00		141.00					40.00		80.00											47.00		94.00				40.00		80.00				47.00				47.00			1.56	1.33		1.56	1.33	1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
S1030	010	0		29	10	S1030_010_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											98.83	34		34				88.63	29		29										34		34				29		29			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		70.00	35.00		70.00	35.00		70.00	35.00		35.00
S1030	010	0		29	10	S1030_010_0	1			Specialty Tier	4	11	1	1	5	1		110	01		110	1				30		90	1	2				30		90	30		31											1.00	25		25				1.00	25		25										25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2468	003	0		29	10	S2468_003_0	4			Preferred Generic	3	01	1	2	1	1		111	01	100		1				30	60	90	2	2			90				30		31								9.00	18.00	27.00					1.00	2.00	2.00							2.00																9.00				9.00			0.30	0.03				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2468	003	0		29	10	S2468_003_0	4			Generic	3	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					14.00	28.00	28.00							28.00																20.00				20.00			0.67	0.47				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2468	003	0		29	10	S2468_003_0	4			Preferred Brand	3	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					45.00	90.00	90.00							90.00																47.00				47.00			1.57	1.50				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	90.00			90.00				35.00		35.00
S2468	003	0		29	10	S2468_003_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	100		1				30	60	90	2	2			90				30		31											75.51	50	50	50				70.98	47	47	47						47															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
S2468	003	0		29	10	S2468_003_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											1265.61	25						1265.61	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2468	004	0		29	10	S2468_004_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	2	2			90				30		31								11.00	22.00	33.00					2.00	4.00	4.00							4.00																11.00				11.00			0.37	0.07				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2468	004	0		29	10	S2468_004_0	4			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								14.00	28.00	42.00					7.00	14.00	14.00							14.00																14.00				14.00			0.47	0.23				0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2468	004	0		29	10	S2468_004_0	4			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	90	2	2			90				30		31								47.00	94.00	141.00					43.00	86.00	86.00							86.00																47.00				47.00			1.57	1.43				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	86.00			86.00				35.00		35.00
S2468	004	0		29	10	S2468_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	2	2			90				30		31											85.92	50	50	50				80.19	47	47	47						47															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00			105.00				35.00		35.00
S2468	004	0		29	10	S2468_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1359.35	33						1359.35	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	005	0		29	10	S2668_005_0	2			Preferred Generic	2	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	005	0		29	10	S2668_005_0	2			Generic	2	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	12.00	24.00	36.00																			12.00	24.00	36.00																12.00				12.00		0.40			0.40			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	005	0		29	10	S2668_005_0	2			Preferred Brand	2	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S2668	005	0		29	10	S2668_005_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				69.18	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S2668	005	0		29	10	S2668_005_0	2			Specialty Tier	2	11	1	1	5	1	010		01	010		1	30								30						30		31				770.96	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	006	0		29	10	S2668_006_0	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								15.00	30.00	45.00					1.00	2.00	3.00					0.00	0.00	0.00																15.00				15.00			0.50	0.03	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	006	0		29	10	S2668_006_0	3			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					9.00	18.00	27.00					0.00	0.00	0.00																20.00				20.00			0.67	0.30	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	006	0		29	10	S2668_006_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	126.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S2668	006	0		29	10	S2668_006_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											56.11	50	50	50				33.83	45	45	45				45	45	45															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2668	006	0		29	10	S2668_006_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1109.56	33						1172.35	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S2874	001	0		29	10	S2874_001_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								2.00		6.00					1.00		3.00											2.00		6.00				1.00		0.00				2.00				2.00			0.07	0.03		0.07	0.03	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													2.00		6.00	1.00		3.00	2.00		6.00	1.00		0.00	2.00		2.00
S2874	001	0		29	10	S2874_001_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								2.00		6.00					1.00		3.00											2.00		6.00				1.00		0.00				2.00				2.00			0.07	0.03		0.07	0.03	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S2874	001	0		29	10	S2874_001_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								4.00		12.00					2.00		6.00											4.00		12.00				2.00		0.00				4.00				4.00			0.13	0.07		0.13	0.07	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													4.00		12.00	2.00		6.00	4.00		12.00	2.00		0.00	4.00		4.00
S2874	001	0		29	10	S2874_001_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								4.00		12.00					2.00		6.00											4.00		12.00				2.00		0.00				4.00				4.00			0.13	0.07		0.13	0.07	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S2874	001	0		29	10	S2874_001_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S2874	001	0		29	10	S2874_001_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	50		50				98.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S2874	001	0		29	10	S2874_001_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												26							26												26						26					26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S2874	001	0		29	10	S2874_001_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S2874	001	0		29	10	S2874_001_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S2874	004	0		29	10	S2874_004_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S2874	004	0		29	10	S2874_004_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S2874	004	0		29	10	S2874_004_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S2874	004	0		29	10	S2874_004_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				91.00	44		44																								44		44				44		30			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S2874	004	0		29	10	S2874_004_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S2893	001	0		29	10	S2893_001_0	3			Preferred Generic	3	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								8.00	16.00	24.00					2.00	4.00	6.00					2.00	2.00	2.00																8.00				8.00			0.27	0.07	0.07			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	2.00	4.00	6.00	2.00	2.00	2.00				8.00		8.00
S2893	001	0		29	10	S2893_001_0	3			Generic	3	11	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	26.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	26.00				20.00		20.00
S2893	001	0		29	10	S2893_001_0	3			Preferred Brand	3	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
S2893	001	0		29	10	S2893_001_0	3			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											99.79	46	46	46				90.08	46	46	46				46	46	46															46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
S2893	001	0		29	10	S2893_001_0	3			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											1.00	25						1.00	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
S2893	003	0		29	10	S2893_003_0	3			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								6.00	12.00	18.00					1.00	2.00	3.00					1.00	1.00	1.00																6.00				6.00			0.20	0.03	0.03			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													6.00	12.00	18.00	1.00	2.00	3.00	1.00	1.00	1.00				6.00		6.00
S2893	003	0		29	10	S2893_003_0	3			Preferred Generic	4	11	1	2	1	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								6.00	12.00	18.00					1.00	2.00	3.00					1.00	1.00	1.00																6.00				6.00			0.20	0.03	0.03			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S2893	003	0		29	10	S2893_003_0	3			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								12.00	24.00	36.00					7.00	14.00	21.00					7.00	14.00	14.00																12.00				12.00			0.40	0.23	0.23			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	36.00	7.00	14.00	21.00	7.00	14.00	14.00				12.00		12.00
S2893	003	0		29	10	S2893_003_0	3			Generic	4	11	1	2	2	3		111	01	111		1				30	60	90	1	2	30	60	90				30		31								12.00	24.00	36.00					7.00	14.00	21.00					7.00	14.00	14.00																12.00				12.00			0.40	0.23	0.23			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S2893	003	0		29	10	S2893_003_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								40.00	80.00	120.00					30.00	60.00	90.00					30.00	60.00	60.00																40.00				40.00			1.33	1.00	1.00			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	30.00	60.00	60.00				35.00		35.00
S2893	003	0		29	10	S2893_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											71.03	44	44	44				54.68	35	35	35				35	35	35															44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00
S2893	003	0		29	10	S2893_003_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1.00	33						1.00	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00						35.00		35.00
S4802	012	0		29	10	S4802_012_0	20			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	012	0		29	10	S4802_012_0	20			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	012	0		29	10	S4802_012_0	20			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.61	20	20	20				20.61	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	012	0		29	10	S4802_012_0	20			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.14	41	41	41				61.14	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	012	0		29	10	S4802_012_0	20			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	012	0		29	10	S4802_012_0	20			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	013	0		29	10	S4802_013_0	20			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	013	0		29	10	S4802_013_0	20			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	013	0		29	10	S4802_013_0	20			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.07	22	22	22				22.07	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	013	0		29	10	S4802_013_0	20			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.98	42	42	42				67.98	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	013	0		29	10	S4802_013_0	20			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	013	0		29	10	S4802_013_0	20			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	014	0		29	10	S4802_014_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	014	0		29	10	S4802_014_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	014	0		29	10	S4802_014_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.13	20	20	20				21.13	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	014	0		29	10	S4802_014_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.29	41	41	41				56.87	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	014	0		29	10	S4802_014_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	014	0		29	10	S4802_014_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	020	0		29	10	S4802_020_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	020	0		29	10	S4802_020_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	020	0		29	10	S4802_020_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.80	22	22	22				21.80	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	020	0		29	10	S4802_020_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.36	42	42	42				62.36	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	020	0		29	10	S4802_020_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	020	0		29	10	S4802_020_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	021	0		29	10	S4802_021_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	021	0		29	10	S4802_021_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	021	0		29	10	S4802_021_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.47	21	21	21				21.47	21	21	21										21	21	21				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	021	0		29	10	S4802_021_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											63.36	41	41	41				61.82	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	021	0		29	10	S4802_021_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	021	0		29	10	S4802_021_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	069	0		29	10	S4802_069_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	069	0		29	10	S4802_069_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	069	0		29	10	S4802_069_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.04	22	22	22				23.04	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	069	0		29	10	S4802_069_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.45	42	42	42				69.45	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	069	0		29	10	S4802_069_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	069	0		29	10	S4802_069_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	070	0		29	10	S4802_070_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	070	0		29	10	S4802_070_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	070	0		29	10	S4802_070_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.87	22	22	22				23.87	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	070	0		29	10	S4802_070_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											64.05	43	43	43				62.56	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	070	0		29	10	S4802_070_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	070	0		29	10	S4802_070_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	071	0		29	10	S4802_071_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	071	0		29	10	S4802_071_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	071	0		29	10	S4802_071_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.78	21	21	21				20.78	21	21	21										21	21	21				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	071	0		29	10	S4802_071_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.56	41	41	41				54.56	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	071	0		29	10	S4802_071_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	071	0		29	10	S4802_071_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	072	0		29	10	S4802_072_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	072	0		29	10	S4802_072_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								7.00	14.00	21.00					3.00	6.00	9.00											7.00	14.00	21.00				3.00	6.00	9.00				7.00				7.00			0.23	0.10		0.23	0.10	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	072	0		29	10	S4802_072_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											18.58	20	20	20				18.58	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	072	0		29	10	S4802_072_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.80	40	40	40				69.80	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	072	0		29	10	S4802_072_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	072	0		29	10	S4802_072_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	073	0		29	10	S4802_073_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	073	0		29	10	S4802_073_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	073	0		29	10	S4802_073_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											19.21	20	20	20				19.21	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	073	0		29	10	S4802_073_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.98	41	41	41				53.98	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	073	0		29	10	S4802_073_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	073	0		29	10	S4802_073_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	074	0		29	10	S4802_074_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	074	0		29	10	S4802_074_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	074	0		29	10	S4802_074_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.46	21	21	21				21.46	21	21	21										21	21	21				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	074	0		29	10	S4802_074_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.69	41	41	41				58.23	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	074	0		29	10	S4802_074_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	074	0		29	10	S4802_074_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	075	0		29	10	S4802_075_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	075	0		29	10	S4802_075_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	075	0		29	10	S4802_075_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.53	22	22	22				21.53	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	075	0		29	10	S4802_075_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											64.43	41	41	41				64.43	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	075	0		29	10	S4802_075_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	075	0		29	10	S4802_075_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	076	0		29	10	S4802_076_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	076	0		29	10	S4802_076_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	076	0		29	10	S4802_076_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.41	22	22	22				23.41	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	076	0		29	10	S4802_076_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.83	43	43	43				68.20	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	076	0		29	10	S4802_076_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	076	0		29	10	S4802_076_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	077	0		29	10	S4802_077_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	077	0		29	10	S4802_077_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	077	0		29	10	S4802_077_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.84	22	22	22				23.84	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	077	0		29	10	S4802_077_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											78.11	41	41	41				76.20	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	077	0		29	10	S4802_077_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	077	0		29	10	S4802_077_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	078	0		29	10	S4802_078_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	078	0		29	10	S4802_078_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	078	0		29	10	S4802_078_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.34	22	22	22				22.34	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	078	0		29	10	S4802_078_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.44	43	43	43				72.44	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	078	0		29	10	S4802_078_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	078	0		29	10	S4802_078_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	079	0		29	10	S4802_079_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	079	0		29	10	S4802_079_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	079	0		29	10	S4802_079_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.86	22	22	22				22.86	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	079	0		29	10	S4802_079_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											71.53	42	42	42				71.53	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	079	0		29	10	S4802_079_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	079	0		29	10	S4802_079_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	080	0		29	10	S4802_080_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	080	0		29	10	S4802_080_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	080	0		29	10	S4802_080_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.47	22	22	22				24.47	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	080	0		29	10	S4802_080_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											64.15	41	41	41				64.15	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	080	0		29	10	S4802_080_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	080	0		29	10	S4802_080_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	081	0		29	10	S4802_081_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	081	0		29	10	S4802_081_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	081	0		29	10	S4802_081_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.44	22	22	22				23.44	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	081	0		29	10	S4802_081_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											63.14	40	40	40				63.14	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	081	0		29	10	S4802_081_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	081	0		29	10	S4802_081_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	082	0		29	10	S4802_082_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	082	0		29	10	S4802_082_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	082	0		29	10	S4802_082_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.22	22	22	22				23.22	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	082	0		29	10	S4802_082_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.66	41	41	41				59.66	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	082	0		29	10	S4802_082_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	082	0		29	10	S4802_082_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	083	0		29	10	S4802_083_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	083	0		29	10	S4802_083_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	083	0		29	10	S4802_083_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.60	22	22	22				22.60	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	083	0		29	10	S4802_083_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.59	41	41	41				64.97	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	083	0		29	10	S4802_083_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	083	0		29	10	S4802_083_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	084	0		29	10	S4802_084_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	084	0		29	10	S4802_084_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	084	0		29	10	S4802_084_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.40	22	22	22				21.40	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	084	0		29	10	S4802_084_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.59	41	41	41				58.13	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	084	0		29	10	S4802_084_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	084	0		29	10	S4802_084_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	085	0		29	10	S4802_085_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	085	0		29	10	S4802_085_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	085	0		29	10	S4802_085_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.66	22	22	22				22.66	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	085	0		29	10	S4802_085_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.28	41	41	41				64.66	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	085	0		29	10	S4802_085_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	085	0		29	10	S4802_085_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	086	0		29	10	S4802_086_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	086	0		29	10	S4802_086_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	086	0		29	10	S4802_086_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.95	21	21	21				21.95	21	21	21										21	21	21				21	21	21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	086	0		29	10	S4802_086_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.01	41	41	41				59.52	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	086	0		29	10	S4802_086_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	086	0		29	10	S4802_086_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	087	0		29	10	S4802_087_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	087	0		29	10	S4802_087_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	087	0		29	10	S4802_087_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.11	22	22	22				23.11	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	087	0		29	10	S4802_087_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.07	46	46	46				69.07	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	087	0		29	10	S4802_087_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	087	0		29	10	S4802_087_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	088	0		29	10	S4802_088_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	088	0		29	10	S4802_088_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					4.00	8.00	12.00											8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00			0.27	0.13		0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	088	0		29	10	S4802_088_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.08	20	20	20				20.08	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	088	0		29	10	S4802_088_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.00	41	41	41				62.00	41	41	41										41	41	41				41	41	41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	088	0		29	10	S4802_088_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	088	0		29	10	S4802_088_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	089	0		29	10	S4802_089_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	089	0		29	10	S4802_089_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	089	0		29	10	S4802_089_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											19.54	20	20	20				19.54	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	089	0		29	10	S4802_089_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											65.91	41	41	41				64.30	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	089	0		29	10	S4802_089_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	089	0		29	10	S4802_089_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	090	0		29	10	S4802_090_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	090	0		29	10	S4802_090_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	090	0		29	10	S4802_090_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.51	22	22	22				22.51	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	090	0		29	10	S4802_090_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											62.27	46	46	46				62.27	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	090	0		29	10	S4802_090_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	090	0		29	10	S4802_090_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	091	0		29	10	S4802_091_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	091	0		29	10	S4802_091_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	091	0		29	10	S4802_091_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.70	22	22	22				23.70	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	091	0		29	10	S4802_091_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.11	41	41	41				68.40	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	091	0		29	10	S4802_091_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	091	0		29	10	S4802_091_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	092	0		29	10	S4802_092_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	092	0		29	10	S4802_092_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	092	0		29	10	S4802_092_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.09	23	23	23				24.00	22	22	22										23	23	23				22	22	22			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	092	0		29	10	S4802_092_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.14	47	47	47				70.60	46	46	46										47	47	47				46	46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	092	0		29	10	S4802_092_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	092	0		29	10	S4802_092_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	093	0		29	10	S4802_093_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	093	0		29	10	S4802_093_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	093	0		29	10	S4802_093_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.57	23	23	23				23.50	22	22	22										23	23	23				22	22	22			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	093	0		29	10	S4802_093_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.13	45	45	45				64.66	44	44	44										45	45	45				44	44	44			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	093	0		29	10	S4802_093_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	093	0		29	10	S4802_093_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	094	0		29	10	S4802_094_0	17			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	094	0		29	10	S4802_094_0	17			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	094	0		29	10	S4802_094_0	17			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.31	23	23	23				22.30	22	22	22										23	23	23				22	22	22			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	094	0		29	10	S4802_094_0	17			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.68	44	44	44				75.68	44	44	44										44	44	44				44	44	44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	094	0		29	10	S4802_094_0	17			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	094	0		29	10	S4802_094_0	17			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	095	0		29	10	S4802_095_0	16			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	095	0		29	10	S4802_095_0	16			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	095	0		29	10	S4802_095_0	16			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											31.77	24	24	24				31.77	24	24	24										24	24	24				24	24	24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	095	0		29	10	S4802_095_0	16			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											93.13	43	43	43				93.13	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	095	0		29	10	S4802_095_0	16			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	095	0		29	10	S4802_095_0	16			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	096	0		29	10	S4802_096_0	16			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	096	0		29	10	S4802_096_0	16			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					5.00	10.00	15.00											9.00	18.00	27.00				5.00	10.00	15.00				9.00				9.00			0.30	0.17		0.30	0.17	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	096	0		29	10	S4802_096_0	16			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											33.51	25	25	25				32.17	24	24	24										25	25	25				24	24	24			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	096	0		29	10	S4802_096_0	16			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											71.02	48	48	48				71.02	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	096	0		29	10	S4802_096_0	16			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	096	0		29	10	S4802_096_0	16			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	097	0		29	10	S4802_097_0	16			Preferred Generic	2	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	097	0		29	10	S4802_097_0	16			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					5.00	10.00	15.00											8.00	16.00	24.00				5.00	10.00	15.00				8.00				8.00			0.27	0.17		0.27	0.17	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	097	0		29	10	S4802_097_0	16			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											18.98	20	20	20				18.98	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	097	0		29	10	S4802_097_0	16			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.65	41	41	41				65.02	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	097	0		29	10	S4802_097_0	16			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	097	0		29	10	S4802_097_0	16			Select Care Drugs	2	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	132	0		29	10	S4802_132_0	19			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	132	0		29	10	S4802_132_0	19			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	132	0		29	10	S4802_132_0	19			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.70	25	25	25				21.70	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	132	0		29	10	S4802_132_0	19			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.14	50	50	50				44.14	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	132	0		29	10	S4802_132_0	19			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	132	0		29	10	S4802_132_0	19			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	133	0		29	10	S4802_133_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	133	0		29	10	S4802_133_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	133	0		29	10	S4802_133_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											19.52	25	25	25				19.52	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	133	0		29	10	S4802_133_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.53	50	50	50				39.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	133	0		29	10	S4802_133_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	133	0		29	10	S4802_133_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	134	0		29	10	S4802_134_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	134	0		29	10	S4802_134_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	6.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	134	0		29	10	S4802_134_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.26	25	25	25				25.26	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	134	0		29	10	S4802_134_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.32	50	50	50				46.32	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	134	0		29	10	S4802_134_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	134	0		29	10	S4802_134_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	135	0		29	10	S4802_135_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	135	0		29	10	S4802_135_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	135	0		29	10	S4802_135_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.78	25	25	25				22.78	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	135	0		29	10	S4802_135_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.54	50	50	50				46.54	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	135	0		29	10	S4802_135_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	135	0		29	10	S4802_135_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	136	0		29	10	S4802_136_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	136	0		29	10	S4802_136_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	136	0		29	10	S4802_136_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.39	25	25	25				25.39	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	136	0		29	10	S4802_136_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.26	50	50	50				55.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	136	0		29	10	S4802_136_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	136	0		29	10	S4802_136_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	137	0		29	10	S4802_137_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	137	0		29	10	S4802_137_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	137	0		29	10	S4802_137_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											27.73	25	25	25				27.73	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	137	0		29	10	S4802_137_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.81	50	50	50				54.81	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	137	0		29	10	S4802_137_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	137	0		29	10	S4802_137_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	138	0		29	10	S4802_138_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	138	0		29	10	S4802_138_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	138	0		29	10	S4802_138_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.85	25	25	25				25.85	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	138	0		29	10	S4802_138_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											63.70	50	50	50				63.70	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	138	0		29	10	S4802_138_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	138	0		29	10	S4802_138_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	139	0		29	10	S4802_139_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	139	0		29	10	S4802_139_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	139	0		29	10	S4802_139_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.89	25	25	25				24.89	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	139	0		29	10	S4802_139_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											57.73	50	50	50				57.73	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	139	0		29	10	S4802_139_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	139	0		29	10	S4802_139_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					5.00	10.00	15.00											5.00	10.00	15.00				5.00	10.00	15.00				5.00				5.00			0.17	0.17		0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	140	0		29	10	S4802_140_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	140	0		29	10	S4802_140_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	140	0		29	10	S4802_140_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.53	25	25	25				21.53	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	140	0		29	10	S4802_140_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.88	50	50	50				53.88	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	140	0		29	10	S4802_140_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	140	0		29	10	S4802_140_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	141	0		29	10	S4802_141_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	141	0		29	10	S4802_141_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	141	0		29	10	S4802_141_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.54	25	25	25				25.54	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	141	0		29	10	S4802_141_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.29	50	50	50				45.29	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	141	0		29	10	S4802_141_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	141	0		29	10	S4802_141_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	142	0		29	10	S4802_142_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	142	0		29	10	S4802_142_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	142	0		29	10	S4802_142_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.25	25	25	25				23.25	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	142	0		29	10	S4802_142_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.26	50	50	50				44.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	142	0		29	10	S4802_142_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	142	0		29	10	S4802_142_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								2.00	4.00	6.00					2.00	4.00	6.00											2.00	4.00	6.00				2.00	4.00	6.00				2.00				2.00			0.07	0.07		0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	143	0		29	10	S4802_143_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	143	0		29	10	S4802_143_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	143	0		29	10	S4802_143_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.71	25	25	25				23.71	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	143	0		29	10	S4802_143_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.98	50	50	50				44.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	143	0		29	10	S4802_143_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	143	0		29	10	S4802_143_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	144	0		29	10	S4802_144_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	144	0		29	10	S4802_144_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	144	0		29	10	S4802_144_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.48	25	25	25				24.48	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	144	0		29	10	S4802_144_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.21	50	50	50				45.21	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	144	0		29	10	S4802_144_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	144	0		29	10	S4802_144_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	145	0		29	10	S4802_145_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	145	0		29	10	S4802_145_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	145	0		29	10	S4802_145_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.57	25	25	25				23.57	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	145	0		29	10	S4802_145_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.53	50	50	50				44.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	145	0		29	10	S4802_145_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	145	0		29	10	S4802_145_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	146	0		29	10	S4802_146_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	146	0		29	10	S4802_146_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	9.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	146	0		29	10	S4802_146_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.18	25	25	25				24.18	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	146	0		29	10	S4802_146_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											48.77	50	50	50				48.77	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	146	0		29	10	S4802_146_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	146	0		29	10	S4802_146_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	147	0		29	10	S4802_147_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	147	0		29	10	S4802_147_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	147	0		29	10	S4802_147_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											20.98	25	25	25				20.98	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	147	0		29	10	S4802_147_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											40.63	50	50	50				40.63	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	147	0		29	10	S4802_147_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	147	0		29	10	S4802_147_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	148	0		29	10	S4802_148_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	148	0		29	10	S4802_148_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	148	0		29	10	S4802_148_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.65	25	25	25				22.65	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	148	0		29	10	S4802_148_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											48.67	50	50	50				48.67	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	148	0		29	10	S4802_148_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	148	0		29	10	S4802_148_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	149	0		29	10	S4802_149_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					0.00	0.00	0.00											13.00	26.00	39.00				0.00	0.00	0.00				13.00				13.00			0.43	0.00		0.43	0.00	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	149	0		29	10	S4802_149_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	9.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	149	0		29	10	S4802_149_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.75	25	25	25				25.75	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	149	0		29	10	S4802_149_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.34	50	50	50				45.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	149	0		29	10	S4802_149_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	149	0		29	10	S4802_149_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	150	0		29	10	S4802_150_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	150	0		29	10	S4802_150_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	150	0		29	10	S4802_150_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.78	25	25	25				22.78	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	150	0		29	10	S4802_150_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.79	50	50	50				39.79	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	150	0		29	10	S4802_150_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	150	0		29	10	S4802_150_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								2.00	4.00	6.00					2.00	4.00	6.00											2.00	4.00	6.00				2.00	4.00	6.00				2.00				2.00			0.07	0.07		0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	151	0		29	10	S4802_151_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	151	0		29	10	S4802_151_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	6.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	151	0		29	10	S4802_151_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.37	25	25	25				26.37	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	151	0		29	10	S4802_151_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.98	50	50	50				47.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	151	0		29	10	S4802_151_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	151	0		29	10	S4802_151_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								2.00	4.00	6.00					2.00	4.00	6.00											2.00	4.00	6.00				2.00	4.00	6.00				2.00				2.00			0.07	0.07		0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	152	0		29	10	S4802_152_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	152	0		29	10	S4802_152_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	152	0		29	10	S4802_152_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.67	25	25	25				21.67	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	152	0		29	10	S4802_152_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.16	50	50	50				38.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	152	0		29	10	S4802_152_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	152	0		29	10	S4802_152_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	153	0		29	10	S4802_153_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	153	0		29	10	S4802_153_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	153	0		29	10	S4802_153_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.25	25	25	25				21.25	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	153	0		29	10	S4802_153_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.40	50	50	50				34.40	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	153	0		29	10	S4802_153_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	153	0		29	10	S4802_153_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	154	0		29	10	S4802_154_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	154	0		29	10	S4802_154_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	154	0		29	10	S4802_154_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.74	25	25	25				21.74	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	154	0		29	10	S4802_154_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											36.34	50	50	50				36.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	154	0		29	10	S4802_154_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	154	0		29	10	S4802_154_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	155	0		29	10	S4802_155_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	155	0		29	10	S4802_155_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	155	0		29	10	S4802_155_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.03	25	25	25				21.03	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	155	0		29	10	S4802_155_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.22	50	50	50				45.22	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	155	0		29	10	S4802_155_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	155	0		29	10	S4802_155_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	156	0		29	10	S4802_156_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	156	0		29	10	S4802_156_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	156	0		29	10	S4802_156_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.14	25	25	25				21.14	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	156	0		29	10	S4802_156_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.08	50	50	50				38.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	156	0		29	10	S4802_156_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	156	0		29	10	S4802_156_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	157	0		29	10	S4802_157_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	157	0		29	10	S4802_157_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	157	0		29	10	S4802_157_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.50	25	25	25				21.50	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	157	0		29	10	S4802_157_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.95	50	50	50				41.95	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	157	0		29	10	S4802_157_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	157	0		29	10	S4802_157_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	158	0		29	10	S4802_158_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	158	0		29	10	S4802_158_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	158	0		29	10	S4802_158_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											24.51	25	25	25				24.51	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	158	0		29	10	S4802_158_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.27	50	50	50				46.27	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	158	0		29	10	S4802_158_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	158	0		29	10	S4802_158_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	159	0		29	10	S4802_159_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	159	0		29	10	S4802_159_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	159	0		29	10	S4802_159_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											21.97	25	25	25				21.97	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	159	0		29	10	S4802_159_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.31	50	50	50				41.31	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	159	0		29	10	S4802_159_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	159	0		29	10	S4802_159_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	160	0		29	10	S4802_160_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	160	0		29	10	S4802_160_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	160	0		29	10	S4802_160_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											27.36	25	25	25				27.36	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	160	0		29	10	S4802_160_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											48.86	50	50	50				48.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	160	0		29	10	S4802_160_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	160	0		29	10	S4802_160_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	161	0		29	10	S4802_161_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	161	0		29	10	S4802_161_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	9.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	161	0		29	10	S4802_161_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.19	25	25	25				23.19	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	161	0		29	10	S4802_161_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.64	50	50	50				50.64	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	161	0		29	10	S4802_161_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	161	0		29	10	S4802_161_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	162	0		29	10	S4802_162_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	162	0		29	10	S4802_162_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	162	0		29	10	S4802_162_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											22.34	25	25	25				22.34	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	162	0		29	10	S4802_162_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.07	50	50	50				37.07	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	162	0		29	10	S4802_162_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	162	0		29	10	S4802_162_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	163	0		29	10	S4802_163_0	16			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	163	0		29	10	S4802_163_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	163	0		29	10	S4802_163_0	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											23.86	25	25	25				23.86	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	163	0		29	10	S4802_163_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.01	50	50	50				52.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	163	0		29	10	S4802_163_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	163	0		29	10	S4802_163_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	164	0		29	10	S4802_164_0	16			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	164	0		29	10	S4802_164_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	164	0		29	10	S4802_164_0	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.22	25	25	25				25.22	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	164	0		29	10	S4802_164_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											56.70	50	50	50				56.70	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	164	0		29	10	S4802_164_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	164	0		29	10	S4802_164_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	165	0		29	10	S4802_165_0	16			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	165	0		29	10	S4802_165_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	165	0		29	10	S4802_165_0	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.94	25	25	25				26.94	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	165	0		29	10	S4802_165_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.56	50	50	50				52.56	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	165	0		29	10	S4802_165_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	165	0		29	10	S4802_165_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	33.00				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	204	0		29	10	S4802_204_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	204	0		29	10	S4802_204_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	204	0		29	10	S4802_204_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	204	0		29	10	S4802_204_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.83	50	50	50				75.83	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	204	0		29	10	S4802_204_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	204	0		29	10	S4802_204_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	205	0		29	10	S4802_205_0	18			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	205	0		29	10	S4802_205_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	205	0		29	10	S4802_205_0	18			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	205	0		29	10	S4802_205_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											85.54	50	50	50				85.54	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	205	0		29	10	S4802_205_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	205	0		29	10	S4802_205_0	18			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	206	0		29	10	S4802_206_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	206	0		29	10	S4802_206_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	206	0		29	10	S4802_206_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	206	0		29	10	S4802_206_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											90.73	50	50	50				90.73	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	206	0		29	10	S4802_206_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	206	0		29	10	S4802_206_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	207	0		29	10	S4802_207_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	207	0		29	10	S4802_207_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	207	0		29	10	S4802_207_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	207	0		29	10	S4802_207_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											81.51	50	50	50				81.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	207	0		29	10	S4802_207_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	207	0		29	10	S4802_207_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	208	0		29	10	S4802_208_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	208	0		29	10	S4802_208_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	208	0		29	10	S4802_208_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	208	0		29	10	S4802_208_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.20	50	50	50				86.20	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	208	0		29	10	S4802_208_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	208	0		29	10	S4802_208_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	209	0		29	10	S4802_209_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	209	0		29	10	S4802_209_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	209	0		29	10	S4802_209_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	209	0		29	10	S4802_209_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											77.84	50	50	50				77.84	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	209	0		29	10	S4802_209_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	209	0		29	10	S4802_209_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	210	0		29	10	S4802_210_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	210	0		29	10	S4802_210_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	210	0		29	10	S4802_210_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	210	0		29	10	S4802_210_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											81.67	50	50	50				81.67	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	210	0		29	10	S4802_210_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	210	0		29	10	S4802_210_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	211	0		29	10	S4802_211_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	211	0		29	10	S4802_211_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	211	0		29	10	S4802_211_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	211	0		29	10	S4802_211_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											78.71	50	50	50				78.71	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	211	0		29	10	S4802_211_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	211	0		29	10	S4802_211_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	212	0		29	10	S4802_212_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	212	0		29	10	S4802_212_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	212	0		29	10	S4802_212_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	212	0		29	10	S4802_212_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											75.70	50	50	50				75.70	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	212	0		29	10	S4802_212_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	212	0		29	10	S4802_212_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	213	0		29	10	S4802_213_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	213	0		29	10	S4802_213_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	213	0		29	10	S4802_213_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	213	0		29	10	S4802_213_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											80.36	50	50	50				80.36	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	213	0		29	10	S4802_213_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	213	0		29	10	S4802_213_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	214	0		29	10	S4802_214_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	214	0		29	10	S4802_214_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	214	0		29	10	S4802_214_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	214	0		29	10	S4802_214_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											80.96	50	50	50				80.96	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	214	0		29	10	S4802_214_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	214	0		29	10	S4802_214_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	215	0		29	10	S4802_215_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	215	0		29	10	S4802_215_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	215	0		29	10	S4802_215_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	215	0		29	10	S4802_215_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.17	50	50	50				79.17	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	215	0		29	10	S4802_215_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	215	0		29	10	S4802_215_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	216	0		29	10	S4802_216_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	216	0		29	10	S4802_216_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	216	0		29	10	S4802_216_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	216	0		29	10	S4802_216_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											78.53	50	50	50				78.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	216	0		29	10	S4802_216_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	216	0		29	10	S4802_216_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	217	0		29	10	S4802_217_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	217	0		29	10	S4802_217_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	217	0		29	10	S4802_217_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	217	0		29	10	S4802_217_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											76.13	50	50	50				76.13	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	217	0		29	10	S4802_217_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	217	0		29	10	S4802_217_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	218	0		29	10	S4802_218_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	218	0		29	10	S4802_218_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	218	0		29	10	S4802_218_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	218	0		29	10	S4802_218_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											74.76	50	50	50				74.76	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	218	0		29	10	S4802_218_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	218	0		29	10	S4802_218_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	219	0		29	10	S4802_219_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	219	0		29	10	S4802_219_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	219	0		29	10	S4802_219_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	219	0		29	10	S4802_219_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											88.45	50	50	50				88.45	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	219	0		29	10	S4802_219_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	219	0		29	10	S4802_219_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	220	0		29	10	S4802_220_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	220	0		29	10	S4802_220_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	220	0		29	10	S4802_220_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	220	0		29	10	S4802_220_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											73.10	50	50	50				73.10	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	220	0		29	10	S4802_220_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	220	0		29	10	S4802_220_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	221	0		29	10	S4802_221_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	221	0		29	10	S4802_221_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	221	0		29	10	S4802_221_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	221	0		29	10	S4802_221_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											77.53	50	50	50				77.53	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	221	0		29	10	S4802_221_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	221	0		29	10	S4802_221_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	222	0		29	10	S4802_222_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	222	0		29	10	S4802_222_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	222	0		29	10	S4802_222_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	222	0		29	10	S4802_222_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.12	50	50	50				66.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	222	0		29	10	S4802_222_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	222	0		29	10	S4802_222_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	223	0		29	10	S4802_223_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	223	0		29	10	S4802_223_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	223	0		29	10	S4802_223_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	223	0		29	10	S4802_223_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.54	50	50	50				70.54	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	223	0		29	10	S4802_223_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	223	0		29	10	S4802_223_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	224	0		29	10	S4802_224_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	224	0		29	10	S4802_224_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	224	0		29	10	S4802_224_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	224	0		29	10	S4802_224_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.12	50	50	50				70.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	224	0		29	10	S4802_224_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	224	0		29	10	S4802_224_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	225	0		29	10	S4802_225_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	225	0		29	10	S4802_225_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	225	0		29	10	S4802_225_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	225	0		29	10	S4802_225_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.20	50	50	50				79.20	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	225	0		29	10	S4802_225_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	225	0		29	10	S4802_225_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	226	0		29	10	S4802_226_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	226	0		29	10	S4802_226_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	226	0		29	10	S4802_226_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	226	0		29	10	S4802_226_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											63.18	50	50	50				63.18	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	226	0		29	10	S4802_226_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	226	0		29	10	S4802_226_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	227	0		29	10	S4802_227_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	227	0		29	10	S4802_227_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	227	0		29	10	S4802_227_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	227	0		29	10	S4802_227_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.67	50	50	50				70.67	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	227	0		29	10	S4802_227_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	227	0		29	10	S4802_227_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	228	0		29	10	S4802_228_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	228	0		29	10	S4802_228_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	228	0		29	10	S4802_228_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	228	0		29	10	S4802_228_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											76.24	50	50	50				76.24	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	228	0		29	10	S4802_228_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	228	0		29	10	S4802_228_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	229	0		29	10	S4802_229_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	229	0		29	10	S4802_229_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	229	0		29	10	S4802_229_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	229	0		29	10	S4802_229_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											84.05	50	50	50				84.05	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	229	0		29	10	S4802_229_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	229	0		29	10	S4802_229_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	230	0		29	10	S4802_230_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	230	0		29	10	S4802_230_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	230	0		29	10	S4802_230_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	230	0		29	10	S4802_230_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											82.11	50	50	50				82.11	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	230	0		29	10	S4802_230_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	230	0		29	10	S4802_230_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	231	0		29	10	S4802_231_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	231	0		29	10	S4802_231_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	231	0		29	10	S4802_231_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	231	0		29	10	S4802_231_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.19	50	50	50				86.19	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	231	0		29	10	S4802_231_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	231	0		29	10	S4802_231_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	232	0		29	10	S4802_232_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	232	0		29	10	S4802_232_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	232	0		29	10	S4802_232_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	232	0		29	10	S4802_232_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											84.78	50	50	50				84.78	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	232	0		29	10	S4802_232_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	232	0		29	10	S4802_232_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	233	0		29	10	S4802_233_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	233	0		29	10	S4802_233_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	233	0		29	10	S4802_233_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	233	0		29	10	S4802_233_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											77.59	50	50	50				77.59	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	233	0		29	10	S4802_233_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	233	0		29	10	S4802_233_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	234	0		29	10	S4802_234_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	234	0		29	10	S4802_234_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	234	0		29	10	S4802_234_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	234	0		29	10	S4802_234_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											80.94	50	50	50				80.94	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	234	0		29	10	S4802_234_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	234	0		29	10	S4802_234_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	235	0		29	10	S4802_235_0	17			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	235	0		29	10	S4802_235_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	235	0		29	10	S4802_235_0	17			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	235	0		29	10	S4802_235_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.06	50	50	50				87.06	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	235	0		29	10	S4802_235_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	235	0		29	10	S4802_235_0	17			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	236	0		29	10	S4802_236_0	16			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	236	0		29	10	S4802_236_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	236	0		29	10	S4802_236_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	236	0		29	10	S4802_236_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											81.21	50	50	50				81.21	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	236	0		29	10	S4802_236_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	236	0		29	10	S4802_236_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	237	0		29	10	S4802_237_0	16			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	237	0		29	10	S4802_237_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	10.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S4802	237	0		29	10	S4802_237_0	16			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	117.50				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	237	0		29	10	S4802_237_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											87.08	50	50	50				87.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S4802	237	0		29	10	S4802_237_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S4802	237	0		29	10	S4802_237_0	16			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00											11.00	22.00	33.00				11.00	22.00	27.50				11.00				11.00			0.37	0.37		0.37	0.37	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																											
S5540	002	0		29	10	S5540_002_0	6			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				5.00	10.00	15.00				15.00				15.00			0.50	0.17		0.50	0.17	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	5.00	10.00	15.00	15.00	30.00	45.00	5.00	10.00	15.00	15.00		15.00
S5540	002	0		29	10	S5540_002_0	6			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		20.00
S5540	002	0		29	10	S5540_002_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.35	16	16	16				39.95	15	15	15										16	16	16				15	15	15			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5540	002	0		29	10	S5540_002_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.23	40	40	40				94.29	39	39	39										40	40	40				39	39	39			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5540	002	0		29	10	S5540_002_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31											1041.71	25						888.39	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5540	004	0		29	10	S5540_004_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	9.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	9.00	15.00		15.00
S5540	004	0		29	10	S5540_004_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	9.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5540	004	0		29	10	S5540_004_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	18.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	18.00	20.00		20.00
S5540	004	0		29	10	S5540_004_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5540	004	0		29	10	S5540_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											99.70	41	41	41				97.53	40	40	40										41	41	41				40	40	40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5540	004	0		29	10	S5540_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1467.67	33						1308.37	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5552	004	0		29	10	S5552_004_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5552	004	0		29	10	S5552_004_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5552	004	0		29	10	S5552_004_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				48.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5552	004	0		29	10	S5552_004_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				84.00	42		42																								42		42				42		30			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5552	004	0		29	10	S5552_004_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5552	005	0		29	10	S5552_005_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5552	005	0		29	10	S5552_005_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5552	005	0		29	10	S5552_005_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5552	005	0		29	10	S5552_005_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5552	005	0		29	10	S5552_005_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5552	005	0		29	10	S5552_005_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											73.00	47		47				61.00	39		39										47		47				39		39			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5552	005	0		29	10	S5552_005_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5552	005	0		29	10	S5552_005_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5552	005	0		29	10	S5552_005_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5552	006	0		29	10	S5552_006_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5552	006	0		29	10	S5552_006_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5552	006	0		29	10	S5552_006_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5552	006	0		29	10	S5552_006_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5552	006	0		29	10	S5552_006_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											43.00	18		18				31.00	13		13										18		18				13		13			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5552	006	0		29	10	S5552_006_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	44		44				100.00	44		44										44		44				44		44			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5552	006	0		29	10	S5552_006_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5584	001	0		29	10	S5584_001_0	2			Preferred Generic	3	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								5.00		15.00					0.00		0.00											5.00		15.00				0.00		0.00				5.00				5.00			0.16	0.00		0.16	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5584	001	0		29	10	S5584_001_0	2			Generic	3	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								18.00		54.00					11.00		0.00											18.00		54.00				11.00		0.00				18.00				18.00			0.58	0.35		0.58	0.35	0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5584	001	0		29	10	S5584_001_0	2			Preferred Brand	3	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								47.00		141.00					42.00		126.00											47.00		141.00				42.00		126.00				47.00				47.00			1.52	1.35		1.52	1.35	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5584	001	0		29	10	S5584_001_0	2			Non-Preferred Drug	3	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											99.00	38		38				90.00	38		38										38		38				38		38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5584	001	0		29	10	S5584_001_0	2			Specialty Tier	3	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	25						1.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5584	002	0		29	10	S5584_002_0	2			Preferred Generic	4	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								6.00		18.00					1.00		0.00											6.00		18.00				1.00		0.00				6.00				6.00			0.19	0.03		0.19	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5584	002	0		29	10	S5584_002_0	2			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								10.00		30.00					5.00		0.00											10.00		30.00				5.00		0.00				10.00				10.00			0.32	0.16		0.32	0.16	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5584	002	0		29	10	S5584_002_0	2			Preferred Brand	4	11	1	2	3	1		110	01		110	1				31		90	1	2				31		90	31		31								45.00		135.00					40.00		120.00											45.00		135.00				40.00		120.00				45.00				45.00			1.45	1.29		1.45	1.29	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5584	002	0		29	10	S5584_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											77.00	45		45				78.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5584	002	0		29	10	S5584_002_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5593	002	0		29	10	S5593_002_0	4			Preferred Generic	2	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								5.00		15.00					0.00		0.00													10.00						0.00				5.00				5.00			0.16	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5593	002	0		29	10	S5593_002_0	4			Generic	2	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								12.00		36.00					7.00		21.00													30.00						17.50				12.00				12.00			0.39	0.23				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5593	002	0		29	10	S5593_002_0	4			Preferred Brand	2	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											52.81	25		25				52.81	20		20												25						20			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5593	002	0		29	10	S5593_002_0	4			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.51	50		50				72.51	40		40												50						40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5593	002	0		29	10	S5593_002_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				31								31			31		31											953.96	25						953.96	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5593	003	0		29	10	S5593_003_0	5			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								4.00		12.00					0.00		0.00													10.00						0.00				4.00				4.00			0.13	0.00				0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5593	003	0		29	10	S5593_003_0	5			Preferred Generic	4	01	1	1	1	3		110	01		100	1				31		100	1	2						100	31		31											0.90	15		15				0.90	10		10												15						10			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5593	003	0		29	10	S5593_003_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								10.00		30.00					5.00		15.00													25.00						12.50				10.00				10.00			0.32	0.16				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5593	003	0		29	10	S5593_003_0	5			Generic	4	01	1	1	2	3		110	01		100	1				31		100	1	2						100	31		31											3.19	15		15				3.19	10		10												15						10			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5593	003	0		29	10	S5593_003_0	5			Preferred Brand	4	11	1	2	3	1		110	01		100	1				31		90	1	2						90	31		31								45.00		135.00					40.00		120.00													112.50						100.00				45.00				45.00			1.45	1.29				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			100.00	35.00		35.00
S5593	003	0		29	10	S5593_003_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											71.33	50		50				71.33	35		35												50						35			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5593	003	0		29	10	S5593_003_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1403.55	33						1403.55	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	001	0		29	10	S5596_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	001	0		29	10	S5596_001_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	001	0		29	10	S5596_001_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	001	0		29	10	S5596_001_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.54	50	50	50				56.54	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	001	0		29	10	S5596_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	005	0		29	10	S5596_005_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								4.00	8.00	12.00					1.00	2.00	3.00					1.00	2.00	3.00																4.00				4.00			0.13	0.03	0.03			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	005	0		29	10	S5596_005_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								6.00	12.00	18.00					3.00	6.00	9.00					3.00	6.00	9.00																6.00				6.00			0.20	0.10	0.10			0.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	005	0		29	10	S5596_005_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											31.96	20	20	20				31.96	20	20	20				20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	005	0		29	10	S5596_005_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.68	40	40	40				64.68	40	40	40				40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	005	0		29	10	S5596_005_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	006	0		29	10	S5596_006_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	006	0		29	10	S5596_006_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	006	0		29	10	S5596_006_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	006	0		29	10	S5596_006_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.03	50	50	50				53.03	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	006	0		29	10	S5596_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	013	0		29	10	S5596_013_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								4.00	8.00	12.00					1.00	2.00	3.00					1.00	2.00	3.00																4.00				4.00			0.13	0.03	0.03			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	013	0		29	10	S5596_013_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								6.00	12.00	18.00					4.00	8.00	12.00					4.00	8.00	12.00																6.00				6.00			0.20	0.13	0.13			0.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	013	0		29	10	S5596_013_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											30.63	20	20	20				29.10	19	19	19				19	19	19															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	013	0		29	10	S5596_013_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											67.59	40	40	40				65.90	39	39	39				39	39	39															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	013	0		29	10	S5596_013_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	014	0		29	10	S5596_014_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	014	0		29	10	S5596_014_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	014	0		29	10	S5596_014_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	014	0		29	10	S5596_014_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.91	50	50	50				55.91	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	014	0		29	10	S5596_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	017	0		29	10	S5596_017_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								3.00	6.00	9.00					1.00	2.00	3.00					1.00	2.00	3.00																3.00				3.00			0.10	0.03	0.03			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	017	0		29	10	S5596_017_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					3.00	6.00	9.00					3.00	6.00	9.00																5.00				5.00			0.17	0.10	0.10			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	017	0		29	10	S5596_017_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											27.24	20	20	20				27.24	20	20	20				20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	017	0		29	10	S5596_017_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											61.65	39	39	39				61.65	39	39	39				39	39	39															39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	017	0		29	10	S5596_017_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	018	0		29	10	S5596_018_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	018	0		29	10	S5596_018_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	018	0		29	10	S5596_018_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	018	0		29	10	S5596_018_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.62	50	50	50				55.62	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	018	0		29	10	S5596_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	043	0		29	10	S5596_043_0	5			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								2.00	4.00	6.00					1.00	2.00	3.00					1.00	2.00	3.00																2.00				2.00			0.07	0.03	0.03			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	043	0		29	10	S5596_043_0	5			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								4.00	8.00	12.00					3.00	6.00	9.00					3.00	6.00	9.00																4.00				4.00			0.13	0.10	0.10			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	043	0		29	10	S5596_043_0	5			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											26.98	20	20	20				26.98	20	20	20				20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	043	0		29	10	S5596_043_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.54	42	42	42				63.98	41	41	41				41	41	41															42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	043	0		29	10	S5596_043_0	5			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	044	0		29	10	S5596_044_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	044	0		29	10	S5596_044_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	044	0		29	10	S5596_044_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	044	0		29	10	S5596_044_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.91	50	50	50				52.91	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	044	0		29	10	S5596_044_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	046	0		29	10	S5596_046_0	5			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								3.00	6.00	9.00					1.00	2.00	3.00					1.00	2.00	3.00																3.00				3.00			0.10	0.03	0.03			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	046	0		29	10	S5596_046_0	5			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					3.00	6.00	9.00					3.00	6.00	9.00																5.00				5.00			0.17	0.10	0.10			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	046	0		29	10	S5596_046_0	5			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											34.89	20	20	20				34.89	20	20	20				20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	046	0		29	10	S5596_046_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											69.36	40	40	40				69.36	40	40	40				40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	046	0		29	10	S5596_046_0	5			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	056	0		29	10	S5596_056_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								3.00	6.00	9.00					1.00	2.00	3.00					1.00	2.00	3.00																3.00				3.00			0.10	0.03	0.03			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	056	0		29	10	S5596_056_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								4.00	8.00	12.00					2.00	4.00	6.00					2.00	4.00	6.00																4.00				4.00			0.13	0.07	0.07			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	056	0		29	10	S5596_056_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											28.82	20	20	20				28.82	20	20	20				20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	056	0		29	10	S5596_056_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.48	39	39	39				56.98	38	38	38				38	38	38															39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	056	0		29	10	S5596_056_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	057	0		29	10	S5596_057_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	057	0		29	10	S5596_057_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	057	0		29	10	S5596_057_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	057	0		29	10	S5596_057_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.52	50	50	50				55.52	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	057	0		29	10	S5596_057_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	059	0		29	10	S5596_059_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								3.00	6.00	9.00					1.00	2.00	3.00					1.00	2.00	3.00																3.00				3.00			0.10	0.03	0.03			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	059	0		29	10	S5596_059_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								6.00	12.00	18.00					4.00	8.00	12.00					4.00	8.00	12.00																6.00				6.00			0.20	0.13	0.13			0.18	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	059	0		29	10	S5596_059_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											32.56	19	19	19				32.56	19	19	19				19	19	19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	059	0		29	10	S5596_059_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.38	38	38	38				75.38	38	38	38				38	38	38															38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	059	0		29	10	S5596_059_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	060	0		29	10	S5596_060_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	060	0		29	10	S5596_060_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	060	0		29	10	S5596_060_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	060	0		29	10	S5596_060_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											61.04	50	50	50				61.04	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	060	0		29	10	S5596_060_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	062	0		29	10	S5596_062_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								3.00	6.00	9.00					1.00	2.00	3.00					1.00	2.00	3.00																3.00				3.00			0.10	0.03	0.03			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	062	0		29	10	S5596_062_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								4.00	8.00	12.00					2.00	4.00	6.00					2.00	4.00	6.00																4.00				4.00			0.13	0.07	0.07			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	062	0		29	10	S5596_062_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											29.98	19	19	19				29.98	19	19	19				19	19	19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	062	0		29	10	S5596_062_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.16	40	40	40				70.16	40	40	40				40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	062	0		29	10	S5596_062_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	063	0		29	10	S5596_063_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	063	0		29	10	S5596_063_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	063	0		29	10	S5596_063_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	063	0		29	10	S5596_063_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.16	50	50	50				65.16	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	063	0		29	10	S5596_063_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	085	0		29	10	S5596_085_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								2.00	4.00	6.00					1.00	2.00	3.00					1.00	2.00	3.00																2.00				2.00			0.07	0.03	0.03			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	085	0		29	10	S5596_085_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								4.00	8.00	12.00					3.00	6.00	9.00					3.00	6.00	9.00																4.00				4.00			0.13	0.10	0.10			0.12	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	085	0		29	10	S5596_085_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											27.24	19	19	19				27.24	19	19	19				19	19	19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	085	0		29	10	S5596_085_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.64	40	40	40				71.80	39	39	39				39	39	39															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	085	0		29	10	S5596_085_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	086	0		29	10	S5596_086_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	086	0		29	10	S5596_086_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	086	0		29	10	S5596_086_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	086	0		29	10	S5596_086_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											60.54	50	50	50				60.54	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	086	0		29	10	S5596_086_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	087	0		29	10	S5596_087_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								2.00	4.00	6.00					1.00	2.00	3.00					1.00	2.00	3.00																2.00				2.00			0.07	0.03	0.03			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	087	0		29	10	S5596_087_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								3.00	6.00	9.00					2.00	4.00	6.00					2.00	4.00	6.00																3.00				3.00			0.10	0.07	0.07			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	087	0		29	10	S5596_087_0	4			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											28.44	19	19	19				28.44	19	19	19				19	19	19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	087	0		29	10	S5596_087_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											68.65	38	38	38				68.65	38	38	38				38	38	38															38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	087	0		29	10	S5596_087_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	088	0		29	10	S5596_088_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	088	0		29	10	S5596_088_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5596	088	0		29	10	S5596_088_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	088	0		29	10	S5596_088_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											68.45	50	50	50				68.45	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5596	088	0		29	10	S5596_088_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	002	0		29	10	S5601_002_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	002	0		29	10	S5601_002_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	002	0		29	10	S5601_002_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											52.94	16	16	16				66.81	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	002	0		29	10	S5601_002_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											62.64	36	36	36				60.43	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	002	0		29	10	S5601_002_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											828.64	25						592.11	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	003	0		29	10	S5601_003_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	003	0		29	10	S5601_003_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	003	0		29	10	S5601_003_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	003	0		29	10	S5601_003_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	003	0		29	10	S5601_003_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	003	0		29	10	S5601_003_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											87.87	50	50	50				62.20	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	003	0		29	10	S5601_003_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1301.63	30						816.74	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	004	0		29	10	S5601_004_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	004	0		29	10	S5601_004_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	004	0		29	10	S5601_004_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											49.04	16	16	16				64.40	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	004	0		29	10	S5601_004_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											63.64	36	36	36				59.65	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	004	0		29	10	S5601_004_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											862.66	25						664.65	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	005	0		29	10	S5601_005_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	005	0		29	10	S5601_005_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	005	0		29	10	S5601_005_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	005	0		29	10	S5601_005_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	005	0		29	10	S5601_005_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	005	0		29	10	S5601_005_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											98.97	50	50	50				73.00	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	005	0		29	10	S5601_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1197.93	30						892.05	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	006	0		29	10	S5601_006_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	006	0		29	10	S5601_006_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	006	0		29	10	S5601_006_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											53.14	16	16	16				65.34	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	006	0		29	10	S5601_006_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											70.74	36	36	36				62.94	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	006	0		29	10	S5601_006_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											819.49	25						615.03	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	007	0		29	10	S5601_007_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	007	0		29	10	S5601_007_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	007	0		29	10	S5601_007_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	007	0		29	10	S5601_007_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	007	0		29	10	S5601_007_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	007	0		29	10	S5601_007_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											99.92	48	48	48				79.03	48	48	48										48	48	48				48	48	48				48		48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	007	0		29	10	S5601_007_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1135.69	30						791.79	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	008	0		29	10	S5601_008_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	008	0		29	10	S5601_008_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	008	0		29	10	S5601_008_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.47	16	16	16				69.12	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	008	0		29	10	S5601_008_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											72.61	40	40	40				65.65	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	008	0		29	10	S5601_008_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											820.11	25						609.38	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	009	0		29	10	S5601_009_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	009	0		29	10	S5601_009_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	009	0		29	10	S5601_009_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	009	0		29	10	S5601_009_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	009	0		29	10	S5601_009_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	009	0		29	10	S5601_009_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											94.24	50	50	50				70.85	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	009	0		29	10	S5601_009_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1211.20	30						795.30	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	010	0		29	10	S5601_010_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	010	0		29	10	S5601_010_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	010	0		29	10	S5601_010_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											54.66	16	16	16				67.92	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	010	0		29	10	S5601_010_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											65.95	35	35	35				64.70	35	35	35										35	35	35				35	35	35				35		35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	010	0		29	10	S5601_010_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											838.48	25						743.67	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	011	0		29	10	S5601_011_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	011	0		29	10	S5601_011_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	011	0		29	10	S5601_011_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	011	0		29	10	S5601_011_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	011	0		29	10	S5601_011_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	011	0		29	10	S5601_011_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											92.83	50	50	50				71.34	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	011	0		29	10	S5601_011_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1115.33	30						788.63	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	012	0		29	10	S5601_012_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	012	0		29	10	S5601_012_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	012	0		29	10	S5601_012_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											52.54	16	16	16				67.27	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	012	0		29	10	S5601_012_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											61.50	35	35	35				61.15	35	35	35										35	35	35				35	35	35				35		35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	012	0		29	10	S5601_012_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											933.50	25						679.92	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	013	0		29	10	S5601_013_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	013	0		29	10	S5601_013_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	013	0		29	10	S5601_013_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	013	0		29	10	S5601_013_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	013	0		29	10	S5601_013_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	013	0		29	10	S5601_013_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											87.87	50	50	50				67.37	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	013	0		29	10	S5601_013_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1258.04	30						691.70	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	014	0		29	10	S5601_014_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	014	0		29	10	S5601_014_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	014	0		29	10	S5601_014_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											59.67	16	16	16				72.11	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	014	0		29	10	S5601_014_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											71.86	46	46	46				69.94	46	46	46										46	46	46				46	46	46				46		46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	014	0		29	10	S5601_014_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											925.78	25						611.54	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	015	0		29	10	S5601_015_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	015	0		29	10	S5601_015_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	015	0		29	10	S5601_015_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	015	0		29	10	S5601_015_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	015	0		29	10	S5601_015_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	015	0		29	10	S5601_015_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											81.87	50	50	50				64.65	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	015	0		29	10	S5601_015_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1430.87	30						801.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	016	0		29	10	S5601_016_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	016	0		29	10	S5601_016_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	016	0		29	10	S5601_016_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.07	16	16	16				70.80	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	016	0		29	10	S5601_016_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											64.33	40	40	40				59.92	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	016	0		29	10	S5601_016_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1023.56	25						602.64	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	017	0		29	10	S5601_017_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	017	0		29	10	S5601_017_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	017	0		29	10	S5601_017_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	017	0		29	10	S5601_017_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	017	0		29	10	S5601_017_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	017	0		29	10	S5601_017_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											84.05	50	50	50				56.17	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	017	0		29	10	S5601_017_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1310.94	30						732.30	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	018	0		29	10	S5601_018_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	018	0		29	10	S5601_018_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	018	0		29	10	S5601_018_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											58.42	16	16	16				70.94	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	018	0		29	10	S5601_018_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											64.40	40	40	40				61.35	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	018	0		29	10	S5601_018_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1058.43	25						545.06	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	019	0		29	10	S5601_019_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	019	0		29	10	S5601_019_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	019	0		29	10	S5601_019_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	019	0		29	10	S5601_019_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	019	0		29	10	S5601_019_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	019	0		29	10	S5601_019_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											83.95	50	50	50				60.38	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	019	0		29	10	S5601_019_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1299.56	30						894.61	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	020	0		29	10	S5601_020_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	020	0		29	10	S5601_020_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	020	0		29	10	S5601_020_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											57.51	16	16	16				72.18	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	020	0		29	10	S5601_020_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											57.32	42	42	42				58.91	42	42	42										42	42	42				42	42	42				42		42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	020	0		29	10	S5601_020_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											979.83	25						589.40	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	021	0		29	10	S5601_021_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	021	0		29	10	S5601_021_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	021	0		29	10	S5601_021_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	021	0		29	10	S5601_021_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	021	0		29	10	S5601_021_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	021	0		29	10	S5601_021_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											75.47	50	50	50				59.90	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	021	0		29	10	S5601_021_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1446.86	30						729.48	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	022	0		29	10	S5601_022_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	022	0		29	10	S5601_022_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	022	0		29	10	S5601_022_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											51.65	16	16	16				70.96	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	022	0		29	10	S5601_022_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											66.55	40	40	40				61.64	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	022	0		29	10	S5601_022_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											888.42	25						618.68	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	023	0		29	10	S5601_023_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	023	0		29	10	S5601_023_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	023	0		29	10	S5601_023_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	023	0		29	10	S5601_023_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	023	0		29	10	S5601_023_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	023	0		29	10	S5601_023_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											89.60	50	50	50				66.59	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	023	0		29	10	S5601_023_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1146.91	30						750.92	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	024	0		29	10	S5601_024_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	024	0		29	10	S5601_024_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	024	0		29	10	S5601_024_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.52	16	16	16				70.71	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	024	0		29	10	S5601_024_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											54.82	40	40	40				54.21	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	024	0		29	10	S5601_024_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1035.05	25						558.66	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	025	0		29	10	S5601_025_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	025	0		29	10	S5601_025_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	025	0		29	10	S5601_025_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	025	0		29	10	S5601_025_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	025	0		29	10	S5601_025_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	025	0		29	10	S5601_025_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											71.21	50	50	50				51.08	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	025	0		29	10	S5601_025_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1344.86	30						648.10	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	026	0		29	10	S5601_026_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	026	0		29	10	S5601_026_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	026	0		29	10	S5601_026_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											52.72	16	16	16				68.40	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	026	0		29	10	S5601_026_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											62.84	40	40	40				60.15	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	026	0		29	10	S5601_026_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											965.55	25						579.91	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	027	0		29	10	S5601_027_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	027	0		29	10	S5601_027_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	027	0		29	10	S5601_027_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	027	0		29	10	S5601_027_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	027	0		29	10	S5601_027_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	027	0		29	10	S5601_027_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											83.10	50	50	50				58.77	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	027	0		29	10	S5601_027_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1244.36	30						779.56	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	028	0		29	10	S5601_028_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	028	0		29	10	S5601_028_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	028	0		29	10	S5601_028_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.78	16	16	16				72.02	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	028	0		29	10	S5601_028_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											69.53	46	46	46				68.52	46	46	46										46	46	46				46	46	46				46		46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	028	0		29	10	S5601_028_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1019.50	25						568.99	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	029	0		29	10	S5601_029_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	029	0		29	10	S5601_029_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	029	0		29	10	S5601_029_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	029	0		29	10	S5601_029_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	029	0		29	10	S5601_029_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	029	0		29	10	S5601_029_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											83.78	50	50	50				61.05	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	029	0		29	10	S5601_029_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1226.54	30						748.86	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	030	0		29	10	S5601_030_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	030	0		29	10	S5601_030_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	030	0		29	10	S5601_030_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											54.24	16	16	16				69.77	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	030	0		29	10	S5601_030_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.40	40	40	40				60.10	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	030	0		29	10	S5601_030_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1012.94	25						581.46	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	031	0		29	10	S5601_031_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	031	0		29	10	S5601_031_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	031	0		29	10	S5601_031_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	031	0		29	10	S5601_031_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	031	0		29	10	S5601_031_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	031	0		29	10	S5601_031_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											73.86	50	50	50				55.79	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	031	0		29	10	S5601_031_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1211.90	30						669.57	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	032	0		29	10	S5601_032_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	032	0		29	10	S5601_032_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	032	0		29	10	S5601_032_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											48.43	16	16	16				61.97	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	032	0		29	10	S5601_032_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.17	30	30	30				55.84	30	30	30										30	30	30				30	30	30				30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	032	0		29	10	S5601_032_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											950.64	25						700.55	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	033	0		29	10	S5601_033_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	033	0		29	10	S5601_033_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	033	0		29	10	S5601_033_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	033	0		29	10	S5601_033_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	033	0		29	10	S5601_033_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	033	0		29	10	S5601_033_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											78.11	50	50	50				56.00	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	033	0		29	10	S5601_033_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1284.48	30						663.59	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	034	0		29	10	S5601_034_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	034	0		29	10	S5601_034_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	034	0		29	10	S5601_034_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.24	16	16	16				70.21	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	034	0		29	10	S5601_034_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											71.10	46	46	46				67.93	46	46	46										46	46	46				46	46	46				46		46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	034	0		29	10	S5601_034_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1038.09	25						547.72	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	035	0		29	10	S5601_035_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	035	0		29	10	S5601_035_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	035	0		29	10	S5601_035_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	035	0		29	10	S5601_035_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	035	0		29	10	S5601_035_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	035	0		29	10	S5601_035_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											81.20	50	50	50				67.76	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	035	0		29	10	S5601_035_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1251.51	30						828.16	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	036	0		29	10	S5601_036_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	036	0		29	10	S5601_036_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	036	0		29	10	S5601_036_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.66	16	16	16				67.92	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	036	0		29	10	S5601_036_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.39	40	40	40				59.34	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	036	0		29	10	S5601_036_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											909.15	25						608.57	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	037	0		29	10	S5601_037_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	037	0		29	10	S5601_037_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	037	0		29	10	S5601_037_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	037	0		29	10	S5601_037_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	037	0		29	10	S5601_037_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	037	0		29	10	S5601_037_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											74.15	50	50	50				52.94	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	037	0		29	10	S5601_037_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1352.22	30						811.96	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	038	0		29	10	S5601_038_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	038	0		29	10	S5601_038_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	038	0		29	10	S5601_038_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.92	16	16	16				67.54	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	038	0		29	10	S5601_038_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											51.36	40	40	40				55.31	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	038	0		29	10	S5601_038_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1049.70	25						494.26	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	040	0		29	10	S5601_040_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	040	0		29	10	S5601_040_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	040	0		29	10	S5601_040_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											65.97	16	16	16				72.01	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	040	0		29	10	S5601_040_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											53.25	40	40	40				54.01	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	040	0		29	10	S5601_040_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											986.59	25						557.44	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	041	0		29	10	S5601_041_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	041	0		29	10	S5601_041_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	041	0		29	10	S5601_041_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	041	0		29	10	S5601_041_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	041	0		29	10	S5601_041_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	041	0		29	10	S5601_041_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											67.73	50	50	50				51.54	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	041	0		29	10	S5601_041_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1417.40	30						830.70	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	042	0		29	10	S5601_042_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	042	0		29	10	S5601_042_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	042	0		29	10	S5601_042_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											59.19	16	16	16				70.47	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	042	0		29	10	S5601_042_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											53.11	36	36	36				52.53	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	042	0		29	10	S5601_042_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											868.64	25						599.28	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	044	0		29	10	S5601_044_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	044	0		29	10	S5601_044_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	044	0		29	10	S5601_044_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											59.00	16	16	16				71.23	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	044	0		29	10	S5601_044_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											66.19	40	40	40				61.11	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	044	0		29	10	S5601_044_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											902.76	25						595.31	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	045	0		29	10	S5601_045_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	045	0		29	10	S5601_045_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	045	0		29	10	S5601_045_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	045	0		29	10	S5601_045_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	045	0		29	10	S5601_045_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	045	0		29	10	S5601_045_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											86.29	50	50	50				66.43	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	045	0		29	10	S5601_045_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1244.37	30						747.84	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	046	0		29	10	S5601_046_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	046	0		29	10	S5601_046_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	046	0		29	10	S5601_046_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											63.60	16	16	16				67.16	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	046	0		29	10	S5601_046_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											52.47	36	36	36				53.14	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	046	0		29	10	S5601_046_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											952.58	25						552.43	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	048	0		29	10	S5601_048_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	048	0		29	10	S5601_048_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	048	0		29	10	S5601_048_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											56.45	16	16	16				69.96	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	048	0		29	10	S5601_048_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											56.84	36	36	36				58.14	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	048	0		29	10	S5601_048_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											997.03	25						542.11	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	049	0		29	10	S5601_049_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	049	0		29	10	S5601_049_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	049	0		29	10	S5601_049_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	049	0		29	10	S5601_049_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	049	0		29	10	S5601_049_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	049	0		29	10	S5601_049_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											67.22	50	50	50				51.13	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	049	0		29	10	S5601_049_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1197.48	30						844.67	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	050	0		29	10	S5601_050_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	050	0		29	10	S5601_050_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	050	0		29	10	S5601_050_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											50.70	16	16	16				63.15	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	050	0		29	10	S5601_050_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											57.17	33	33	33				56.60	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	050	0		29	10	S5601_050_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											936.21	25						692.30	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	051	0		29	10	S5601_051_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	051	0		29	10	S5601_051_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	051	0		29	10	S5601_051_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	051	0		29	10	S5601_051_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	051	0		29	10	S5601_051_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	051	0		29	10	S5601_051_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											72.78	50	50	50				57.79	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	051	0		29	10	S5601_051_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1243.07	30						894.77	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	052	0		29	10	S5601_052_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	052	0		29	10	S5601_052_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	052	0		29	10	S5601_052_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											58.65	16	16	16				65.70	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	052	0		29	10	S5601_052_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											62.96	35	35	35				65.20	35	35	35										35	35	35				35	35	35				35		35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	052	0		29	10	S5601_052_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1038.80	25						739.86	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	053	0		29	10	S5601_053_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	053	0		29	10	S5601_053_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	053	0		29	10	S5601_053_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	053	0		29	10	S5601_053_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	053	0		29	10	S5601_053_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	053	0		29	10	S5601_053_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											90.37	50	50	50				67.86	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	053	0		29	10	S5601_053_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1174.62	30						738.88	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	054	0		29	10	S5601_054_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	054	0		29	10	S5601_054_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	054	0		29	10	S5601_054_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											56.38	16	16	16				68.90	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	054	0		29	10	S5601_054_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											69.49	40	40	40				68.65	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	054	0		29	10	S5601_054_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											961.35	25						692.55	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	055	0		29	10	S5601_055_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	055	0		29	10	S5601_055_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	055	0		29	10	S5601_055_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	055	0		29	10	S5601_055_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	055	0		29	10	S5601_055_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	055	0		29	10	S5601_055_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											83.16	50	50	50				63.01	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	055	0		29	10	S5601_055_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1096.92	30						651.18	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	056	0		29	10	S5601_056_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	056	0		29	10	S5601_056_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	056	0		29	10	S5601_056_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.05	16	16	16				71.16	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	056	0		29	10	S5601_056_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											79.67	46	46	46				71.56	46	46	46										46	46	46				46	46	46				46		46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	056	0		29	10	S5601_056_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											934.10	25						617.89	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	057	0		29	10	S5601_057_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	057	0		29	10	S5601_057_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	057	0		29	10	S5601_057_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	057	0		29	10	S5601_057_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	057	0		29	10	S5601_057_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	057	0		29	10	S5601_057_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											95.80	50	50	50				68.36	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	057	0		29	10	S5601_057_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1438.36	30						852.48	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	058	0		29	10	S5601_058_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	058	0		29	10	S5601_058_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	058	0		29	10	S5601_058_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											52.21	16	16	16				68.21	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	058	0		29	10	S5601_058_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											72.66	42	42	42				66.12	42	42	42										42	42	42				42	42	42				42		42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	058	0		29	10	S5601_058_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											1074.96	25						700.51	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	059	0		29	10	S5601_059_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	059	0		29	10	S5601_059_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	059	0		29	10	S5601_059_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	059	0		29	10	S5601_059_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	059	0		29	10	S5601_059_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	059	0		29	10	S5601_059_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											80.41	50	50	50				64.73	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	059	0		29	10	S5601_059_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1225.96	30						690.09	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	060	0		29	10	S5601_060_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	060	0		29	10	S5601_060_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	060	0		29	10	S5601_060_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.51	16	16	16				66.31	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	060	0		29	10	S5601_060_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											59.17	40	40	40				61.35	40	40	40										40	40	40				40	40	40				40		40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	060	0		29	10	S5601_060_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											883.81	25						655.16	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	061	0		29	10	S5601_061_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	061	0		29	10	S5601_061_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	061	0		29	10	S5601_061_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	061	0		29	10	S5601_061_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	061	0		29	10	S5601_061_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	061	0		29	10	S5601_061_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											80.96	50	50	50				64.81	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	061	0		29	10	S5601_061_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1225.27	30						847.17	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	062	0		29	10	S5601_062_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	062	0		29	10	S5601_062_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	062	0		29	10	S5601_062_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											57.08	16	16	16				66.53	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	062	0		29	10	S5601_062_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.08	33	33	33				61.84	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	062	0		29	10	S5601_062_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											844.90	25						694.67	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	063	0		29	10	S5601_063_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	063	0		29	10	S5601_063_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	063	0		29	10	S5601_063_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	063	0		29	10	S5601_063_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	063	0		29	10	S5601_063_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	063	0		29	10	S5601_063_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											74.53	50	50	50				54.59	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	063	0		29	10	S5601_063_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1095.70	30						608.41	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	064	0		29	10	S5601_064_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	064	0		29	10	S5601_064_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	064	0		29	10	S5601_064_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											55.84	16	16	16				65.99	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	064	0		29	10	S5601_064_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											67.71	36	36	36				62.60	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	064	0		29	10	S5601_064_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											786.29	25						622.50	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	065	0		29	10	S5601_065_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	065	0		29	10	S5601_065_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	065	0		29	10	S5601_065_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	065	0		29	10	S5601_065_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	065	0		29	10	S5601_065_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	065	0		29	10	S5601_065_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											93.32	50	50	50				75.93	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	065	0		29	10	S5601_065_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											939.73	30						762.79	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	066	0		29	10	S5601_066_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	066	0		29	10	S5601_066_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	066	0		29	10	S5601_066_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											54.61	16	16	16				72.27	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	066	0		29	10	S5601_066_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											97.56	36	36	36				77.51	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	066	0		29	10	S5601_066_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											892.86	25						734.61	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	067	0		29	10	S5601_067_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	067	0		29	10	S5601_067_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	067	0		29	10	S5601_067_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	067	0		29	10	S5601_067_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	067	0		29	10	S5601_067_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	067	0		29	10	S5601_067_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											88.46	50	50	50				65.78	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	067	0		29	10	S5601_067_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1312.30	30						785.35	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	068	0		29	10	S5601_068_0	3			Preferred Generic	2	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					2.00	4.00	6.00											8.00	16.00	24.00				2.00	4.00	6.00					8.00			8.00			0.27	0.07		0.27	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	068	0		29	10	S5601_068_0	3			Generic	2	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00					15.00			15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	068	0		29	10	S5601_068_0	3			Preferred Brand	2	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											49.08	16	16	16				65.11	16	16	16										16	16	16				16	16	16				16		16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	068	0		29	10	S5601_068_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											56.62	36	36	36				62.95	36	36	36										36	36	36				36	36	36				36		36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	068	0		29	10	S5601_068_0	3			Specialty Tier	2	11	1	1	5	1		010	10		010	1				30								30				10	31											853.38	25						678.69	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	107	0		29	10	S5601_107_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	107	0		29	10	S5601_107_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	107	0		29	10	S5601_107_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	107	0		29	10	S5601_107_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	107	0		29	10	S5601_107_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	107	0		29	10	S5601_107_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											70.35	50	50	50				52.74	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	107	0		29	10	S5601_107_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1376.94	30						896.27	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	108	0		29	10	S5601_108_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	108	0		29	10	S5601_108_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	108	0		29	10	S5601_108_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	108	0		29	10	S5601_108_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	108	0		29	10	S5601_108_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	108	0		29	10	S5601_108_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											76.27	50	50	50				64.82	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	108	0		29	10	S5601_108_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1217.30	30						999.09	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	109	0		29	10	S5601_109_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	109	0		29	10	S5601_109_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	109	0		29	10	S5601_109_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	109	0		29	10	S5601_109_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	109	0		29	10	S5601_109_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	109	0		29	10	S5601_109_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											98.00	50	50	50				78.52	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	109	0		29	10	S5601_109_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1173.30	30						824.84	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	176	0		29	10	S5601_176_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	176	0		29	10	S5601_176_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	176	0		29	10	S5601_176_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											105.90	24	24	24				132.77	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	176	0		29	10	S5601_176_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											70.59	50	50	50				53.79	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	176	0		29	10	S5601_176_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											888.19	29						717.32	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	177	0		29	10	S5601_177_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	177	0		29	10	S5601_177_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	177	0		29	10	S5601_177_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											102.65	24	24	24				131.60	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	177	0		29	10	S5601_177_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											69.96	50	50	50				57.33	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	177	0		29	10	S5601_177_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											792.42	29						674.66	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	178	0		29	10	S5601_178_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	178	0		29	10	S5601_178_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	178	0		29	10	S5601_178_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											85.50	23	23	23				120.81	23	23	23										23	23	23				23	23	23				23		23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	178	0		29	10	S5601_178_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											71.01	50	50	50				57.94	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	178	0		29	10	S5601_178_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											812.02	29						716.49	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	179	0		29	10	S5601_179_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	179	0		29	10	S5601_179_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	179	0		29	10	S5601_179_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											96.98	24	24	24				132.79	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	179	0		29	10	S5601_179_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											70.70	50	50	50				54.89	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	179	0		29	10	S5601_179_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											774.89	29						665.36	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	180	0		29	10	S5601_180_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	180	0		29	10	S5601_180_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	180	0		29	10	S5601_180_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											92.97	24	24	24				130.40	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	180	0		29	10	S5601_180_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											76.47	50	50	50				57.21	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	180	0		29	10	S5601_180_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											883.28	29						753.52	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	181	0		29	10	S5601_181_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	181	0		29	10	S5601_181_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	181	0		29	10	S5601_181_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											108.93	24	24	24				131.56	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	181	0		29	10	S5601_181_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											68.46	50	50	50				53.45	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	181	0		29	10	S5601_181_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											849.23	29						620.92	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	182	0		29	10	S5601_182_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	182	0		29	10	S5601_182_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	182	0		29	10	S5601_182_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											92.75	24	24	24				133.46	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	182	0		29	10	S5601_182_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											61.40	50	50	50				53.90	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	182	0		29	10	S5601_182_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											759.43	29						627.26	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	183	0		29	10	S5601_183_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	183	0		29	10	S5601_183_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	183	0		29	10	S5601_183_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											104.43	24	24	24				136.89	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	183	0		29	10	S5601_183_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											68.89	50	50	50				48.46	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	183	0		29	10	S5601_183_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											779.97	29						622.71	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	184	0		29	10	S5601_184_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	184	0		29	10	S5601_184_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	184	0		29	10	S5601_184_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											103.51	24	24	24				137.60	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	184	0		29	10	S5601_184_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											76.22	50	50	50				51.47	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	184	0		29	10	S5601_184_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1022.14	29						611.88	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	185	0		29	10	S5601_185_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	185	0		29	10	S5601_185_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	185	0		29	10	S5601_185_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											81.63	24	24	24				136.91	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	185	0		29	10	S5601_185_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											47.24	50	50	50				47.42	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	185	0		29	10	S5601_185_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											932.24	29						684.32	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	186	0		29	10	S5601_186_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	186	0		29	10	S5601_186_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	186	0		29	10	S5601_186_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											81.66	24	24	24				134.87	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	186	0		29	10	S5601_186_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											63.37	50	50	50				49.92	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	186	0		29	10	S5601_186_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											853.21	29						696.79	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	187	0		29	10	S5601_187_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	187	0		29	10	S5601_187_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	187	0		29	10	S5601_187_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											95.25	24	24	24				136.67	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	187	0		29	10	S5601_187_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.87	50	50	50				44.87	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	187	0		29	10	S5601_187_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											899.96	29						586.05	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	188	0		29	10	S5601_188_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	188	0		29	10	S5601_188_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	188	0		29	10	S5601_188_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											103.99	24	24	24				131.00	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	188	0		29	10	S5601_188_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											64.26	50	50	50				49.35	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	188	0		29	10	S5601_188_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											792.20	29						626.20	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	189	0		29	10	S5601_189_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	189	0		29	10	S5601_189_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	189	0		29	10	S5601_189_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											102.26	24	24	24				132.72	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	189	0		29	10	S5601_189_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											69.19	50	50	50				54.19	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	189	0		29	10	S5601_189_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											739.76	29						592.04	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	190	0		29	10	S5601_190_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	190	0		29	10	S5601_190_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	190	0		29	10	S5601_190_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											88.38	24	24	24				132.95	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	190	0		29	10	S5601_190_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											56.42	50	50	50				46.03	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	190	0		29	10	S5601_190_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											872.34	29						599.92	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	191	0		29	10	S5601_191_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	191	0		29	10	S5601_191_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	191	0		29	10	S5601_191_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											102.86	24	24	24				129.28	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	191	0		29	10	S5601_191_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											57.45	50	50	50				59.10	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	191	0		29	10	S5601_191_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											756.51	29						726.27	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	192	0		29	10	S5601_192_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	192	0		29	10	S5601_192_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	192	0		29	10	S5601_192_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											80.53	24	24	24				131.33	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	192	0		29	10	S5601_192_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											57.88	50	50	50				50.24	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	192	0		29	10	S5601_192_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											803.12	29						633.26	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	193	0		29	10	S5601_193_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	193	0		29	10	S5601_193_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	193	0		29	10	S5601_193_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											95.70	24	24	24				131.85	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	193	0		29	10	S5601_193_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											53.16	50	50	50				48.46	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	193	0		29	10	S5601_193_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											772.99	29						645.69	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	194	0		29	10	S5601_194_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	194	0		29	10	S5601_194_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	194	0		29	10	S5601_194_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											111.58	24	24	24				136.22	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	194	0		29	10	S5601_194_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											58.66	50	50	50				49.74	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	194	0		29	10	S5601_194_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											805.75	29						626.34	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	195	0		29	10	S5601_195_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	195	0		29	10	S5601_195_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	195	0		29	10	S5601_195_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											108.20	24	24	24				137.86	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	195	0		29	10	S5601_195_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											51.66	50	50	50				51.14	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	195	0		29	10	S5601_195_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											853.90	29						633.84	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	196	0		29	10	S5601_196_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	196	0		29	10	S5601_196_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	196	0		29	10	S5601_196_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											95.26	24	24	24				137.56	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	196	0		29	10	S5601_196_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											53.50	50	50	50				47.09	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	196	0		29	10	S5601_196_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											798.44	29						691.37	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	197	0		29	10	S5601_197_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	197	0		29	10	S5601_197_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	197	0		29	10	S5601_197_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											90.77	24	24	24				136.20	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	197	0		29	10	S5601_197_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											68.26	50	50	50				52.79	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	197	0		29	10	S5601_197_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											849.39	29						695.38	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	198	0		29	10	S5601_198_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	198	0		29	10	S5601_198_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	198	0		29	10	S5601_198_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											123.36	24	24	24				137.70	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	198	0		29	10	S5601_198_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											56.89	50	50	50				55.15	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	198	0		29	10	S5601_198_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											808.24	29						662.72	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	199	0		29	10	S5601_199_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	199	0		29	10	S5601_199_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	199	0		29	10	S5601_199_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											120.11	24	24	24				140.33	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	199	0		29	10	S5601_199_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											63.25	50	50	50				46.15	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	199	0		29	10	S5601_199_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											756.47	29						560.52	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	200	0		29	10	S5601_200_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	200	0		29	10	S5601_200_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	200	0		29	10	S5601_200_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											115.70	24	24	24				135.53	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	200	0		29	10	S5601_200_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											49.65	50	50	50				50.22	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	200	0		29	10	S5601_200_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											769.04	29						596.19	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	201	0		29	10	S5601_201_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	201	0		29	10	S5601_201_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	201	0		29	10	S5601_201_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											115.23	24	24	24				129.54	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	201	0		29	10	S5601_201_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											65.31	50	50	50				54.02	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	201	0		29	10	S5601_201_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1040.35	29						751.73	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	202	0		29	10	S5601_202_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	202	0		29	10	S5601_202_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	202	0		29	10	S5601_202_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											98.05	24	24	24				129.38	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	202	0		29	10	S5601_202_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											78.69	50	50	50				61.87	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	202	0		29	10	S5601_202_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											957.63	29						707.80	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	203	0		29	10	S5601_203_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	203	0		29	10	S5601_203_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	203	0		29	10	S5601_203_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											94.52	24	24	24				131.26	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	203	0		29	10	S5601_203_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											82.62	50	50	50				54.66	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	203	0		29	10	S5601_203_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											902.11	29						671.91	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	204	0		29	10	S5601_204_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	204	0		29	10	S5601_204_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	204	0		29	10	S5601_204_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											89.44	24	24	24				131.70	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	204	0		29	10	S5601_204_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											77.13	50	50	50				52.22	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	204	0		29	10	S5601_204_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1001.75	29						613.16	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	205	0		29	10	S5601_205_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	205	0		29	10	S5601_205_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	205	0		29	10	S5601_205_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											110.32	24	24	24				135.22	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	205	0		29	10	S5601_205_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											64.81	50	50	50				57.00	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	205	0		29	10	S5601_205_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											733.42	29						668.45	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	206	0		29	10	S5601_206_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	206	0		29	10	S5601_206_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	206	0		29	10	S5601_206_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											115.85	24	24	24				133.25	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	206	0		29	10	S5601_206_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											64.14	50	50	50				54.70	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	206	0		29	10	S5601_206_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											760.23	29						603.03	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	207	0		29	10	S5601_207_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	207	0		29	10	S5601_207_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	207	0		29	10	S5601_207_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											105.45	24	24	24				133.90	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	207	0		29	10	S5601_207_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											73.07	50	50	50				57.70	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	207	0		29	10	S5601_207_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											887.32	29						738.52	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	208	0		29	10	S5601_208_0	3			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	208	0		29	10	S5601_208_0	3			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	208	0		29	10	S5601_208_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											106.05	24	24	24				134.65	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	208	0		29	10	S5601_208_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											63.70	50	50	50				58.73	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	208	0		29	10	S5601_208_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1039.10	29						873.00	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	209	0		29	10	S5601_209_0	4			Preferred Generic	4	01	1	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								8.00	16.00	24.00					0.00	0.00	0.00											8.00	16.00	24.00				0.00	0.00	0.00					8.00			8.00			0.27	0.00		0.27	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	209	0		29	10	S5601_209_0	4			Generic	4	01	1	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	15.00					12.00			12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	209	0		29	10	S5601_209_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											96.06	24	24	24				133.18	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	209	0		29	10	S5601_209_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											60.04	50	50	50				57.71	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	209	0		29	10	S5601_209_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											807.72	29						690.15	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5601	210	0		29	10	S5601_210_0	3			Preferred Generic	4	01	3	2	1	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	210	0		29	10	S5601_210_0	3			Preferred Generic	4	01	3	2	1	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00					5.00			5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	210	0		29	10	S5601_210_0	3			Generic	4	01	3	2	2	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	210	0		29	10	S5601_210_0	3			Generic	4	01	3	2	2	3		111	10		111	1				30	60	90	1	2				30	60	90		10	31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00					10.00			10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1		3															
S5601	210	0		29	10	S5601_210_0	3			Preferred Brand	4	11	1	2	3	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00					47.00			47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5601	210	0		29	10	S5601_210_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	90	1	2				30	60	90		10	31											87.50	50	50	50				69.07	50	50	50										50	50	50				50	50	50				50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5601	210	0		29	10	S5601_210_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											1215.20	30						805.67	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5609	001	0		29	10	S5609_001_0	5			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					4.00	8.00	12.00					4.00	8.00	12.00																10.00				10.00			0.33	0.13	0.13			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	4.00	8.00	12.00	4.00	8.00	12.00				10.00		10.00
S5609	001	0		29	10	S5609_001_0	5			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					13.00	26.00	39.00					13.00	26.00	39.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	13.00	26.00	39.00				20.00		20.00
S5609	001	0		29	10	S5609_001_0	5			Preferred Brand	3	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5609	001	0		29	10	S5609_001_0	5			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											60.46	45	45	45				53.75	40	40	40				40	40	40															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5609	001	0		29	10	S5609_001_0	5			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											926.97	25						926.97	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5609	002	0		29	10	S5609_002_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	6.00				3.00	6.00	6.00				3.00		3.00
S5609	002	0		29	10	S5609_002_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5609	002	0		29	10	S5609_002_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
S5609	002	0		29	10	S5609_002_0	7			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	117.50																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S5609	002	0		29	10	S5609_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				53.75	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S5609	002	0		29	10	S5609_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1223.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5617	003	0		29	10	S5617_003_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	003	0		29	10	S5617_003_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	003	0		29	10	S5617_003_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											26.90	16	16	16				28.64	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	003	0		29	10	S5617_003_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											61.89	43	43	43				51.66	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	003	0		29	10	S5617_003_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	008	0		29	10	S5617_008_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	008	0		29	10	S5617_008_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	008	0		29	10	S5617_008_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											30.55	16	16	16				34.57	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	008	0		29	10	S5617_008_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											64.72	46	46	46				58.05	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	008	0		29	10	S5617_008_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	013	0		29	10	S5617_013_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	9.00	0.00	0.00	0.00	3.00	6.00	9.00	0.00	0.00	0.00	3.00		3.00
S5617	013	0		29	10	S5617_013_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					3.00	6.00	9.00											7.00	14.00	21.00				3.00	6.00	3.00				7.00				7.00			0.23	0.10		0.23	0.10	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	3.00	6.00	9.00	7.00	14.00	21.00	3.00	6.00	3.00	7.00		7.00
S5617	013	0		29	10	S5617_013_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											30.85	16	16	16				34.00	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	013	0		29	10	S5617_013_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											64.24	43	43	43				58.84	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	013	0		29	10	S5617_013_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	018	0		29	10	S5617_018_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	018	0		29	10	S5617_018_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	018	0		29	10	S5617_018_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											31.73	16	16	16				35.40	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	018	0		29	10	S5617_018_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											64.87	46	46	46				62.17	45	45	45										46	46	46				45	45	45			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	018	0		29	10	S5617_018_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	053	0		29	10	S5617_053_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	053	0		29	10	S5617_053_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	053	0		29	10	S5617_053_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.99	17	17	17				35.80	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	053	0		29	10	S5617_053_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											67.87	44	44	44				57.26	43	43	43										44	44	44				43	43	43			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	053	0		29	10	S5617_053_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	068	0		29	10	S5617_068_0	8			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	068	0		29	10	S5617_068_0	8			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	068	0		29	10	S5617_068_0	8			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.84	17	17	17				29.96	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	068	0		29	10	S5617_068_0	8			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											64.14	44	44	44				53.37	43	43	43										44	44	44				43	43	43			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	068	0		29	10	S5617_068_0	8			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	088	0		29	10	S5617_088_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	088	0		29	10	S5617_088_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	088	0		29	10	S5617_088_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.31	17	17	17				30.75	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	088	0		29	10	S5617_088_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											61.54	48	48	48				56.44	47	47	47										48	48	48				47	47	47			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	088	0		29	10	S5617_088_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	103	0		29	10	S5617_103_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	103	0		29	10	S5617_103_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					3.00	6.00	9.00											7.00	14.00	21.00				3.00	6.00	3.00				7.00				7.00			0.23	0.10		0.23	0.10	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	3.00	6.00	9.00	7.00	14.00	21.00	3.00	6.00	3.00	7.00		7.00
S5617	103	0		29	10	S5617_103_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											30.49	17	17	17				32.02	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	103	0		29	10	S5617_103_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											64.97	43	43	43				58.61	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	103	0		29	10	S5617_103_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	108	0		29	10	S5617_108_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	108	0		29	10	S5617_108_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	108	0		29	10	S5617_108_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											31.54	17	17	17				33.02	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	108	0		29	10	S5617_108_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											66.54	48	48	48				59.31	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	108	0		29	10	S5617_108_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	113	0		29	10	S5617_113_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	113	0		29	10	S5617_113_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	113	0		29	10	S5617_113_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.65	17	17	17				30.54	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	113	0		29	10	S5617_113_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.97	46	46	46				54.05	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	113	0		29	10	S5617_113_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	118	0		29	10	S5617_118_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	118	0		29	10	S5617_118_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	118	0		29	10	S5617_118_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											25.61	17	17	17				26.99	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	118	0		29	10	S5617_118_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.22	43	43	43				44.90	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	118	0		29	10	S5617_118_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	123	0		29	10	S5617_123_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	123	0		29	10	S5617_123_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	123	0		29	10	S5617_123_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											31.60	17	17	17				28.32	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	123	0		29	10	S5617_123_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.97	47	47	47				52.90	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	123	0		29	10	S5617_123_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	128	0		29	10	S5617_128_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	128	0		29	10	S5617_128_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	128	0		29	10	S5617_128_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.55	17	17	17				33.89	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	128	0		29	10	S5617_128_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											77.71	42	42	42				67.63	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	128	0		29	10	S5617_128_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	133	0		29	10	S5617_133_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	133	0		29	10	S5617_133_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	133	0		29	10	S5617_133_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											31.80	17	17	17				29.35	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	133	0		29	10	S5617_133_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											67.14	42	42	42				60.49	41	41	41										42	42	42				41	41	41			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	133	0		29	10	S5617_133_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	138	0		29	10	S5617_138_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	138	0		29	10	S5617_138_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	138	0		29	10	S5617_138_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.71	17	17	17				33.12	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	138	0		29	10	S5617_138_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											77.59	42	42	42				62.43	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	138	0		29	10	S5617_138_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	143	0		29	10	S5617_143_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	143	0		29	10	S5617_143_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					3.00	6.00	9.00											9.00	18.00	27.00				3.00	6.00	3.00				9.00				9.00			0.30	0.10		0.30	0.10	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	3.00	6.00	9.00	9.00	18.00	27.00	3.00	6.00	3.00	9.00		9.00
S5617	143	0		29	10	S5617_143_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											32.75	17	17	17				36.42	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	143	0		29	10	S5617_143_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											78.64	44	44	44				72.21	43	43	43										44	44	44				43	43	43			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	143	0		29	10	S5617_143_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	148	0		29	10	S5617_148_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	148	0		29	10	S5617_148_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	148	0		29	10	S5617_148_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.51	17	17	17				28.01	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	148	0		29	10	S5617_148_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											61.68	42	42	42				53.93	41	41	41										42	42	42				41	41	41			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	148	0		29	10	S5617_148_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	153	0		29	10	S5617_153_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	153	0		29	10	S5617_153_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	153	0		29	10	S5617_153_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.63	17	17	17				29.01	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	153	0		29	10	S5617_153_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											66.11	43	43	43				56.76	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	153	0		29	10	S5617_153_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	158	0		29	10	S5617_158_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	4.00	6.00	0.00	0.00	0.00	2.00	4.00	6.00	0.00	0.00	0.00	2.00		2.00
S5617	158	0		29	10	S5617_158_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					3.00	6.00	9.00											7.00	14.00	21.00				3.00	6.00	3.00				7.00				7.00			0.23	0.10		0.23	0.10	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	3.00	6.00	9.00	7.00	14.00	21.00	3.00	6.00	3.00	7.00		7.00
S5617	158	0		29	10	S5617_158_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											32.48	17	17	17				34.24	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	158	0		29	10	S5617_158_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.89	40	40	40				54.90	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	158	0		29	10	S5617_158_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	163	0		29	10	S5617_163_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	163	0		29	10	S5617_163_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					3.00	6.00	9.00											9.00	18.00	27.00				3.00	6.00	3.00				9.00				9.00			0.30	0.10		0.30	0.10	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	3.00	6.00	9.00	9.00	18.00	27.00	3.00	6.00	3.00	9.00		9.00
S5617	163	0		29	10	S5617_163_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.29	17	17	17				39.13	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	163	0		29	10	S5617_163_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											73.03	42	42	42				66.27	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	163	0		29	10	S5617_163_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	214	0		29	10	S5617_214_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	214	0		29	10	S5617_214_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	214	0		29	10	S5617_214_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.88	16	16	16				31.34	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	214	0		29	10	S5617_214_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											69.82	43	43	43				60.87	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	214	0		29	10	S5617_214_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	215	0		29	10	S5617_215_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	215	0		29	10	S5617_215_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	3.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	3.00	8.00		8.00
S5617	215	0		29	10	S5617_215_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.72	16	16	16				31.51	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	215	0		29	10	S5617_215_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.93	43	43	43				50.87	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	215	0		29	10	S5617_215_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	216	0		29	10	S5617_216_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	216	0		29	10	S5617_216_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	216	0		29	10	S5617_216_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.79	17	17	17				34.36	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	216	0		29	10	S5617_216_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.30	48	48	48				58.85	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	216	0		29	10	S5617_216_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	217	0		29	10	S5617_217_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	217	0		29	10	S5617_217_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	217	0		29	10	S5617_217_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.22	17	17	17				35.78	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	217	0		29	10	S5617_217_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											67.31	48	48	48				58.05	47	47	47										48	48	48				47	47	47			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	217	0		29	10	S5617_217_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	218	0		29	10	S5617_218_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	218	0		29	10	S5617_218_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	218	0		29	10	S5617_218_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											30.67	17	17	17				34.89	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	218	0		29	10	S5617_218_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											65.08	47	47	47				58.55	46	46	46										47	47	47				46	46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	218	0		29	10	S5617_218_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	219	0		29	10	S5617_219_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	219	0		29	10	S5617_219_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	219	0		29	10	S5617_219_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.51	17	17	17				32.78	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	219	0		29	10	S5617_219_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.89	47	47	47				52.56	46	46	46										47	47	47				46	46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	219	0		29	10	S5617_219_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	220	0		29	10	S5617_220_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	220	0		29	10	S5617_220_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	220	0		29	10	S5617_220_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.81	17	17	17				32.45	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	220	0		29	10	S5617_220_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.16	46	46	46				49.86	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	220	0		29	10	S5617_220_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	221	0		29	10	S5617_221_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	6.00	9.00					0.00	0.00	0.00											3.00	6.00	9.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	9.00	0.00	0.00	0.00	3.00	6.00	9.00	0.00	0.00	0.00	3.00		3.00
S5617	221	0		29	10	S5617_221_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					3.00	6.00	9.00											7.00	14.00	21.00				3.00	6.00	3.00				7.00				7.00			0.23	0.10		0.23	0.10	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	3.00	6.00	9.00	7.00	14.00	21.00	3.00	6.00	3.00	7.00		7.00
S5617	221	0		29	10	S5617_221_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											25.33	16	16	16				28.38	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	221	0		29	10	S5617_221_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.13	42	42	42				56.67	42	42	42										42	42	42				42	42	42			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	221	0		29	10	S5617_221_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	222	0		29	10	S5617_222_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	222	0		29	10	S5617_222_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								9.00	18.00	27.00					3.00	6.00	9.00											9.00	18.00	27.00				3.00	6.00	3.00				9.00				9.00			0.30	0.10		0.30	0.10	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	3.00	6.00	9.00	9.00	18.00	27.00	3.00	6.00	3.00	9.00		9.00
S5617	222	0		29	10	S5617_222_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.74	17	17	17				31.14	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	222	0		29	10	S5617_222_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.53	47	47	47				54.44	46	46	46										47	47	47				46	46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	222	0		29	10	S5617_222_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	223	0		29	10	S5617_223_0	8			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.07	0.00		0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00	4.00	6.00	0.00	0.00	0.00	2.00	4.00	6.00	0.00	0.00	0.00	2.00		2.00
S5617	223	0		29	10	S5617_223_0	8			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								7.00	14.00	21.00					2.00	4.00	6.00											7.00	14.00	21.00				2.00	4.00	2.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													7.00	14.00	21.00	2.00	4.00	6.00	7.00	14.00	21.00	2.00	4.00	2.00	7.00		7.00
S5617	223	0		29	10	S5617_223_0	8			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.23	16	16	16				26.57	16	16	16										16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	223	0		29	10	S5617_223_0	8			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.08	40	40	40				49.54	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	223	0		29	10	S5617_223_0	8			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	224	0		29	10	S5617_224_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	224	0		29	10	S5617_224_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	224	0		29	10	S5617_224_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											30.29	17	17	17				33.81	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	224	0		29	10	S5617_224_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.49	48	48	48				52.69	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	224	0		29	10	S5617_224_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	225	0		29	10	S5617_225_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	225	0		29	10	S5617_225_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	225	0		29	10	S5617_225_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.40	17	17	17				29.99	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	225	0		29	10	S5617_225_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.10	43	43	43				52.51	42	42	42										43	43	43				42	42	42			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	225	0		29	10	S5617_225_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	226	0		29	10	S5617_226_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	226	0		29	10	S5617_226_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	226	0		29	10	S5617_226_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.67	17	17	17				30.62	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	226	0		29	10	S5617_226_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											49.80	43	43	43				48.98	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	226	0		29	10	S5617_226_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	227	0		29	10	S5617_227_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	227	0		29	10	S5617_227_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	227	0		29	10	S5617_227_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											30.34	17	17	17				31.11	17	17	17										17	17	17				17	17	17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	227	0		29	10	S5617_227_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.49	42	42	42				57.12	41	41	41										42	42	42				41	41	41			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	227	0		29	10	S5617_227_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	246	0		29	10	S5617_246_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	246	0		29	10	S5617_246_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	246	0		29	10	S5617_246_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	246	0		29	10	S5617_246_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	246	0		29	10	S5617_246_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.72	23	23	23				34.25	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	246	0		29	10	S5617_246_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											89.94	50	50	50				78.25	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	246	0		29	10	S5617_246_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	247	0		29	10	S5617_247_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	247	0		29	10	S5617_247_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	247	0		29	10	S5617_247_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	247	0		29	10	S5617_247_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	247	0		29	10	S5617_247_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.98	23	23	23				39.23	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	247	0		29	10	S5617_247_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											72.30	50	50	50				68.06	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	247	0		29	10	S5617_247_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	248	0		29	10	S5617_248_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	248	0		29	10	S5617_248_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	248	0		29	10	S5617_248_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	248	0		29	10	S5617_248_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	248	0		29	10	S5617_248_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.91	23	23	23				36.75	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	248	0		29	10	S5617_248_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											85.99	48	48	48				75.60	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	248	0		29	10	S5617_248_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	249	0		29	10	S5617_249_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	249	0		29	10	S5617_249_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	249	0		29	10	S5617_249_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	249	0		29	10	S5617_249_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	249	0		29	10	S5617_249_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.52	23	23	23				34.05	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	249	0		29	10	S5617_249_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											87.93	49	49	49				73.20	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	249	0		29	10	S5617_249_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	250	0		29	10	S5617_250_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	250	0		29	10	S5617_250_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	250	0		29	10	S5617_250_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	250	0		29	10	S5617_250_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	250	0		29	10	S5617_250_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.78	23	23	23				32.75	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	250	0		29	10	S5617_250_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											85.06	50	50	50				72.02	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	250	0		29	10	S5617_250_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	251	0		29	10	S5617_251_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	251	0		29	10	S5617_251_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	251	0		29	10	S5617_251_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	251	0		29	10	S5617_251_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	251	0		29	10	S5617_251_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.12	23	23	23				36.73	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	251	0		29	10	S5617_251_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											82.52	50	50	50				71.34	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	251	0		29	10	S5617_251_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	252	0		29	10	S5617_252_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	252	0		29	10	S5617_252_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	252	0		29	10	S5617_252_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	252	0		29	10	S5617_252_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	252	0		29	10	S5617_252_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.48	23	23	23				37.02	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	252	0		29	10	S5617_252_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											68.39	50	50	50				62.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	252	0		29	10	S5617_252_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	253	0		29	10	S5617_253_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	253	0		29	10	S5617_253_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	253	0		29	10	S5617_253_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	253	0		29	10	S5617_253_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	253	0		29	10	S5617_253_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.06	23	23	23				33.65	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	253	0		29	10	S5617_253_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											73.03	50	50	50				65.32	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	253	0		29	10	S5617_253_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	254	0		29	10	S5617_254_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	254	0		29	10	S5617_254_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	254	0		29	10	S5617_254_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					11.00	22.00	33.00											20.00	40.00	60.00				11.00	22.00	6.00				20.00				20.00			0.67	0.37		0.67	0.37	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	11.00	22.00	33.00	20.00	40.00	60.00	11.00	22.00	6.00	20.00		20.00
S5617	254	0		29	10	S5617_254_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					11.00	22.00	33.00											20.00	40.00	60.00				11.00	22.00	6.00				20.00				20.00			0.67	0.37		0.67	0.37	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	254	0		29	10	S5617_254_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.33	23	23	23				37.14	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	254	0		29	10	S5617_254_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											72.34	50	50	50				57.52	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	254	0		29	10	S5617_254_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	255	0		29	10	S5617_255_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	255	0		29	10	S5617_255_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	255	0		29	10	S5617_255_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	255	0		29	10	S5617_255_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	255	0		29	10	S5617_255_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.25	23	23	23				33.50	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	255	0		29	10	S5617_255_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											86.18	50	50	50				74.89	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	255	0		29	10	S5617_255_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	256	0		29	10	S5617_256_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	256	0		29	10	S5617_256_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	256	0		29	10	S5617_256_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	256	0		29	10	S5617_256_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	256	0		29	10	S5617_256_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.63	23	23	23				31.12	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	256	0		29	10	S5617_256_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											85.99	46	46	46				71.58	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	256	0		29	10	S5617_256_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	257	0		29	10	S5617_257_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	257	0		29	10	S5617_257_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	257	0		29	10	S5617_257_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	257	0		29	10	S5617_257_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	257	0		29	10	S5617_257_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.83	23	23	23				32.22	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	257	0		29	10	S5617_257_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											76.84	50	50	50				66.44	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	257	0		29	10	S5617_257_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	258	0		29	10	S5617_258_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	258	0		29	10	S5617_258_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	258	0		29	10	S5617_258_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	258	0		29	10	S5617_258_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	258	0		29	10	S5617_258_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.53	23	23	23				37.86	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	258	0		29	10	S5617_258_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.30	50	50	50				69.46	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	258	0		29	10	S5617_258_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	259	0		29	10	S5617_259_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	259	0		29	10	S5617_259_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	259	0		29	10	S5617_259_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	259	0		29	10	S5617_259_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	259	0		29	10	S5617_259_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.30	23	23	23				40.98	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	259	0		29	10	S5617_259_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											74.13	50	50	50				69.86	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	259	0		29	10	S5617_259_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	260	0		29	10	S5617_260_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	260	0		29	10	S5617_260_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	260	0		29	10	S5617_260_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	260	0		29	10	S5617_260_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	260	0		29	10	S5617_260_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.80	23	23	23				36.88	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	260	0		29	10	S5617_260_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											69.20	50	50	50				60.84	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	260	0		29	10	S5617_260_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	261	0		29	10	S5617_261_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	261	0		29	10	S5617_261_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	261	0		29	10	S5617_261_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	261	0		29	10	S5617_261_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	261	0		29	10	S5617_261_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.98	23	23	23				40.79	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	261	0		29	10	S5617_261_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											67.70	50	50	50				57.75	48	48	48										50	50	50				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	261	0		29	10	S5617_261_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	262	0		29	10	S5617_262_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	262	0		29	10	S5617_262_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	262	0		29	10	S5617_262_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	262	0		29	10	S5617_262_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	262	0		29	10	S5617_262_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.89	23	23	23				39.40	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	262	0		29	10	S5617_262_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											74.27	50	50	50				68.48	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	262	0		29	10	S5617_262_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	263	0		29	10	S5617_263_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	263	0		29	10	S5617_263_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	263	0		29	10	S5617_263_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	263	0		29	10	S5617_263_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	263	0		29	10	S5617_263_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.05	23	23	23				31.52	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	263	0		29	10	S5617_263_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											76.46	50	50	50				70.72	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	263	0		29	10	S5617_263_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	264	0		29	10	S5617_264_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	264	0		29	10	S5617_264_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	264	0		29	10	S5617_264_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	264	0		29	10	S5617_264_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	264	0		29	10	S5617_264_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.76	23	23	23				32.52	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	264	0		29	10	S5617_264_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.03	50	50	50				62.42	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	264	0		29	10	S5617_264_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	265	0		29	10	S5617_265_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	265	0		29	10	S5617_265_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	265	0		29	10	S5617_265_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	265	0		29	10	S5617_265_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	265	0		29	10	S5617_265_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.58	23	23	23				34.84	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	265	0		29	10	S5617_265_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.59	50	50	50				50.24	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	265	0		29	10	S5617_265_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	266	0		29	10	S5617_266_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	266	0		29	10	S5617_266_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	266	0		29	10	S5617_266_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	266	0		29	10	S5617_266_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	266	0		29	10	S5617_266_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.20	23	23	23				30.48	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	266	0		29	10	S5617_266_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.06	48	48	48				68.29	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	266	0		29	10	S5617_266_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	267	0		29	10	S5617_267_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	267	0		29	10	S5617_267_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	267	0		29	10	S5617_267_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	267	0		29	10	S5617_267_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	267	0		29	10	S5617_267_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.61	23	23	23				37.85	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	267	0		29	10	S5617_267_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.28	50	50	50				65.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	267	0		29	10	S5617_267_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	268	0		29	10	S5617_268_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	268	0		29	10	S5617_268_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	268	0		29	10	S5617_268_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	268	0		29	10	S5617_268_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	268	0		29	10	S5617_268_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.63	23	23	23				40.08	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	268	0		29	10	S5617_268_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											70.75	50	50	50				57.16	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	268	0		29	10	S5617_268_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	269	0		29	10	S5617_269_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	269	0		29	10	S5617_269_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	269	0		29	10	S5617_269_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	269	0		29	10	S5617_269_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	269	0		29	10	S5617_269_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.17	23	23	23				37.94	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	269	0		29	10	S5617_269_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.48	50	50	50				68.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	269	0		29	10	S5617_269_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	270	0		29	10	S5617_270_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	270	0		29	10	S5617_270_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	270	0		29	10	S5617_270_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	270	0		29	10	S5617_270_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	270	0		29	10	S5617_270_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											47.16	23	23	23				38.24	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	270	0		29	10	S5617_270_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											72.51	50	50	50				66.42	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	270	0		29	10	S5617_270_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	271	0		29	10	S5617_271_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	271	0		29	10	S5617_271_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	271	0		29	10	S5617_271_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	271	0		29	10	S5617_271_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	271	0		29	10	S5617_271_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.40	23	23	23				36.15	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	271	0		29	10	S5617_271_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											92.04	50	50	50				81.45	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	271	0		29	10	S5617_271_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	272	0		29	10	S5617_272_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	272	0		29	10	S5617_272_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	272	0		29	10	S5617_272_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	272	0		29	10	S5617_272_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	272	0		29	10	S5617_272_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.59	23	23	23				32.72	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	272	0		29	10	S5617_272_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											94.67	48	48	48				76.67	47	47	47										48	48	48				47	47	47			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	272	0		29	10	S5617_272_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	273	0		29	10	S5617_273_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	273	0		29	10	S5617_273_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	273	0		29	10	S5617_273_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	273	0		29	10	S5617_273_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	273	0		29	10	S5617_273_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.42	23	23	23				35.74	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	273	0		29	10	S5617_273_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											86.53	50	50	50				73.63	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	273	0		29	10	S5617_273_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	274	0		29	10	S5617_274_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	274	0		29	10	S5617_274_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	274	0		29	10	S5617_274_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	274	0		29	10	S5617_274_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	274	0		29	10	S5617_274_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.91	23	23	23				34.71	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	274	0		29	10	S5617_274_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											84.23	50	50	50				76.59	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	274	0		29	10	S5617_274_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	275	0		29	10	S5617_275_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	275	0		29	10	S5617_275_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	275	0		29	10	S5617_275_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	275	0		29	10	S5617_275_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	275	0		29	10	S5617_275_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.03	23	23	23				38.52	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	275	0		29	10	S5617_275_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											67.53	50	50	50				58.15	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	275	0		29	10	S5617_275_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	276	0		29	10	S5617_276_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	276	0		29	10	S5617_276_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	276	0		29	10	S5617_276_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	276	0		29	10	S5617_276_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	276	0		29	10	S5617_276_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.67	23	23	23				32.94	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	276	0		29	10	S5617_276_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											79.90	50	50	50				65.52	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	276	0		29	10	S5617_276_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	277	0		29	10	S5617_277_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	277	0		29	10	S5617_277_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	277	0		29	10	S5617_277_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	277	0		29	10	S5617_277_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	277	0		29	10	S5617_277_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.32	23	23	23				33.93	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	277	0		29	10	S5617_277_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											80.96	46	46	46				72.01	46	46	46										46	46	46				46	46	46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	277	0		29	10	S5617_277_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	278	0		29	10	S5617_278_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	278	0		29	10	S5617_278_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	278	0		29	10	S5617_278_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	278	0		29	10	S5617_278_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	278	0		29	10	S5617_278_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.41	23	23	23				38.16	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	278	0		29	10	S5617_278_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											94.14	47	47	47				89.87	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	278	0		29	10	S5617_278_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	279	0		29	10	S5617_279_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	279	0		29	10	S5617_279_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	279	0		29	10	S5617_279_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	279	0		29	10	S5617_279_0	5			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	279	0		29	10	S5617_279_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.74	23	23	23				39.18	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	279	0		29	10	S5617_279_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.69	50	50	50				71.07	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	279	0		29	10	S5617_279_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	348	0		29	10	S5617_348_0	7			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								4.00	8.00	12.00					0.00	0.00	0.00											4.00	8.00	12.00				0.00	0.00	0.00				4.00				4.00			0.13	0.00		0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													4.00	8.00	12.00	0.00	0.00	0.00	4.00	8.00	12.00	0.00	0.00	0.00	4.00		4.00
S5617	348	0		29	10	S5617_348_0	7			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								10.00	20.00	30.00					3.00	6.00	9.00											10.00	20.00	30.00				3.00	6.00	3.00				10.00				10.00			0.33	0.10		0.33	0.10	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	10.00	20.00	30.00	3.00	6.00	3.00	10.00		10.00
S5617	348	0		29	10	S5617_348_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											43.31	20	20	20				42.53	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	348	0		29	10	S5617_348_0	7			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											60.82	50	50	50				50.23	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	348	0		29	10	S5617_348_0	7			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	349	0		29	10	S5617_349_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	3.00	6.00	9.00	15.00	30.00	45.00	3.00	6.00	0.00	15.00		15.00
S5617	349	0		29	10	S5617_349_0	6			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					3.00	6.00	9.00											15.00	30.00	45.00				3.00	6.00	0.00				15.00				15.00			0.50	0.10		0.50	0.10	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	349	0		29	10	S5617_349_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	12.00	24.00	36.00	20.00	40.00	60.00	12.00	24.00	6.00	20.00		20.00
S5617	349	0		29	10	S5617_349_0	6			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					12.00	24.00	36.00											20.00	40.00	60.00				12.00	24.00	6.00				20.00				20.00			0.67	0.40		0.67	0.40	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5617	349	0		29	10	S5617_349_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											48.59	23	23	23				27.53	20	20	20										23	23	23				20	20	20			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	349	0		29	10	S5617_349_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											74.82	50	50	50				64.79	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	349	0		29	10	S5617_349_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	351	0		29	10	S5617_351_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	351	0		29	10	S5617_351_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	351	0		29	10	S5617_351_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.97	21	21	21				38.67	20	20	20										21	21	21				20	20	20			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	351	0		29	10	S5617_351_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.38	50	50	50				47.13	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	351	0		29	10	S5617_351_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	352	0		29	10	S5617_352_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	352	0		29	10	S5617_352_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	352	0		29	10	S5617_352_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.61	20	20	20				36.16	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	352	0		29	10	S5617_352_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.22	49	49	49				46.35	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	352	0		29	10	S5617_352_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	353	0		29	10	S5617_353_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	353	0		29	10	S5617_353_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	353	0		29	10	S5617_353_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.23	19	19	19				34.22	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	353	0		29	10	S5617_353_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.45	48	48	48				44.72	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	353	0		29	10	S5617_353_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	354	0		29	10	S5617_354_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	354	0		29	10	S5617_354_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	354	0		29	10	S5617_354_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.65	19	19	19				33.11	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	354	0		29	10	S5617_354_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.99	50	50	50				43.46	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	354	0		29	10	S5617_354_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	355	0		29	10	S5617_355_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	355	0		29	10	S5617_355_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	355	0		29	10	S5617_355_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.27	20	20	20				35.96	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	355	0		29	10	S5617_355_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.38	49	49	49				45.75	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	355	0		29	10	S5617_355_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	356	0		29	10	S5617_356_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	356	0		29	10	S5617_356_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	356	0		29	10	S5617_356_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.65	20	20	20				34.51	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	356	0		29	10	S5617_356_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.74	48	48	48				42.43	48	48	48										48	48	48				48	48	48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	356	0		29	10	S5617_356_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	357	0		29	10	S5617_357_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	357	0		29	10	S5617_357_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	357	0		29	10	S5617_357_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.04	20	20	20				35.48	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	357	0		29	10	S5617_357_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.47	47	47	47				41.36	46	46	46										47	47	47				46	46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	357	0		29	10	S5617_357_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	358	0		29	10	S5617_358_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	358	0		29	10	S5617_358_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	358	0		29	10	S5617_358_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.76	20	20	20				33.92	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	358	0		29	10	S5617_358_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.10	47	47	47				39.77	46	46	46										47	47	47				46	46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	358	0		29	10	S5617_358_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	359	0		29	10	S5617_359_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	359	0		29	10	S5617_359_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	359	0		29	10	S5617_359_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.32	20	20	20				33.90	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	359	0		29	10	S5617_359_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.84	50	50	50				42.54	49	49	49										50	50	50				49	49	49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	359	0		29	10	S5617_359_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	360	0		29	10	S5617_360_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	360	0		29	10	S5617_360_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	360	0		29	10	S5617_360_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.99	20	20	20				31.58	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	360	0		29	10	S5617_360_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.54	48	48	48				40.38	47	47	47										48	48	48				47	47	47			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	360	0		29	10	S5617_360_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	361	0		29	10	S5617_361_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	361	0		29	10	S5617_361_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	361	0		29	10	S5617_361_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.82	20	20	20				34.26	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	361	0		29	10	S5617_361_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.88	50	50	50				43.31	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	361	0		29	10	S5617_361_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	362	0		29	10	S5617_362_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	362	0		29	10	S5617_362_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	362	0		29	10	S5617_362_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.58	19	19	19				31.42	19	19	19										19	19	19				19	19	19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	362	0		29	10	S5617_362_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.72	49	49	49				39.21	48	48	48										49	49	49				48	48	48			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	362	0		29	10	S5617_362_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	363	0		29	10	S5617_363_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	363	0		29	10	S5617_363_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	363	0		29	10	S5617_363_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.12	20	20	20				34.76	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	363	0		29	10	S5617_363_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.19	49	49	49				42.90	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	363	0		29	10	S5617_363_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	364	0		29	10	S5617_364_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	364	0		29	10	S5617_364_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	364	0		29	10	S5617_364_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.43	20	20	20				34.11	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	364	0		29	10	S5617_364_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.15	50	50	50				42.91	49	49	49										50	50	50				49	49	49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	364	0		29	10	S5617_364_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	365	0		29	10	S5617_365_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	365	0		29	10	S5617_365_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	365	0		29	10	S5617_365_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.29	19	19	19				30.81	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	365	0		29	10	S5617_365_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.72	50	50	50				42.19	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	365	0		29	10	S5617_365_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	366	0		29	10	S5617_366_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	366	0		29	10	S5617_366_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					7.00	14.00	21.00											20.00	40.00	60.00				7.00	14.00	6.00				20.00				20.00			0.67	0.23		0.67	0.23	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	7.00	14.00	21.00	20.00	40.00	60.00	7.00	14.00	6.00	20.00		20.00
S5617	366	0		29	10	S5617_366_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.75	20	20	20				33.02	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	366	0		29	10	S5617_366_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.52	50	50	50				42.08	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	366	0		29	10	S5617_366_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	367	0		29	10	S5617_367_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	367	0		29	10	S5617_367_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					7.00	14.00	21.00											20.00	40.00	60.00				7.00	14.00	6.00				20.00				20.00			0.67	0.23		0.67	0.23	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	7.00	14.00	21.00	20.00	40.00	60.00	7.00	14.00	6.00	20.00		20.00
S5617	367	0		29	10	S5617_367_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.39	20	20	20				34.23	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	367	0		29	10	S5617_367_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.10	50	50	50				43.75	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	367	0		29	10	S5617_367_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	368	0		29	10	S5617_368_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	368	0		29	10	S5617_368_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	368	0		29	10	S5617_368_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.99	20	20	20				31.35	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	368	0		29	10	S5617_368_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.26	50	50	50				42.48	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	368	0		29	10	S5617_368_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	369	0		29	10	S5617_369_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	369	0		29	10	S5617_369_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	369	0		29	10	S5617_369_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.10	20	20	20				30.64	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	369	0		29	10	S5617_369_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.39	50	50	50				41.55	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	369	0		29	10	S5617_369_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	370	0		29	10	S5617_370_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	370	0		29	10	S5617_370_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	370	0		29	10	S5617_370_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.49	19	19	19				29.68	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	370	0		29	10	S5617_370_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											52.65	49	49	49				40.56	48	48	48										49	49	49				48	48	48			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	370	0		29	10	S5617_370_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	371	0		29	10	S5617_371_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	371	0		29	10	S5617_371_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	371	0		29	10	S5617_371_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.52	20	20	20				29.77	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	371	0		29	10	S5617_371_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.72	50	50	50				41.04	49	49	49										50	50	50				49	49	49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	371	0		29	10	S5617_371_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	372	0		29	10	S5617_372_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	372	0		29	10	S5617_372_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	372	0		29	10	S5617_372_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.03	20	20	20				32.13	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	372	0		29	10	S5617_372_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.03	50	50	50				42.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	372	0		29	10	S5617_372_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	373	0		29	10	S5617_373_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	373	0		29	10	S5617_373_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	373	0		29	10	S5617_373_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.25	20	20	20				30.53	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	373	0		29	10	S5617_373_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.44	47	47	47				39.01	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	373	0		29	10	S5617_373_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	374	0		29	10	S5617_374_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	374	0		29	10	S5617_374_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	374	0		29	10	S5617_374_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.42	19	19	19				31.18	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	374	0		29	10	S5617_374_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.92	50	50	50				40.73	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	374	0		29	10	S5617_374_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	375	0		29	10	S5617_375_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	375	0		29	10	S5617_375_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	375	0		29	10	S5617_375_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.81	19	19	19				32.39	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	375	0		29	10	S5617_375_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.01	50	50	50				41.25	49	49	49										50	50	50				49	49	49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	375	0		29	10	S5617_375_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	376	0		29	10	S5617_376_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	376	0		29	10	S5617_376_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	376	0		29	10	S5617_376_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.59	20	20	20				37.38	19	19	19										20	20	20				19	19	19			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	376	0		29	10	S5617_376_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.14	49	49	49				45.03	49	49	49										49	49	49				49	49	49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	376	0		29	10	S5617_376_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	377	0		29	10	S5617_377_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	377	0		29	10	S5617_377_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	377	0		29	10	S5617_377_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.96	19	19	19				35.66	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	377	0		29	10	S5617_377_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.01	50	50	50				44.15	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	377	0		29	10	S5617_377_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	378	0		29	10	S5617_378_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	378	0		29	10	S5617_378_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	378	0		29	10	S5617_378_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.18	20	20	20				34.42	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	378	0		29	10	S5617_378_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.33	50	50	50				43.65	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	378	0		29	10	S5617_378_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	379	0		29	10	S5617_379_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	379	0		29	10	S5617_379_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					7.00	14.00	21.00											20.00	40.00	60.00				7.00	14.00	6.00				20.00				20.00			0.67	0.23		0.67	0.23	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	7.00	14.00	21.00	20.00	40.00	60.00	7.00	14.00	6.00	20.00		20.00
S5617	379	0		29	10	S5617_379_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.86	20	20	20				34.63	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	379	0		29	10	S5617_379_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.73	50	50	50				44.83	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	379	0		29	10	S5617_379_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	380	0		29	10	S5617_380_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	380	0		29	10	S5617_380_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	380	0		29	10	S5617_380_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.43	20	20	20				34.75	18	18	18										20	20	20				18	18	18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	380	0		29	10	S5617_380_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											55.93	50	50	50				44.28	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	380	0		29	10	S5617_380_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	381	0		29	10	S5617_381_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	381	0		29	10	S5617_381_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	381	0		29	10	S5617_381_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.39	19	19	19				33.26	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	381	0		29	10	S5617_381_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.11	50	50	50				40.61	48	48	48										50	50	50				48	48	48			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	381	0		29	10	S5617_381_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	382	0		29	10	S5617_382_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	382	0		29	10	S5617_382_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	6.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	6.00	20.00		20.00
S5617	382	0		29	10	S5617_382_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.93	19	19	19				36.11	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	382	0		29	10	S5617_382_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.20	50	50	50				45.51	49	49	49										50	50	50				49	49	49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	382	0		29	10	S5617_382_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	383	0		29	10	S5617_383_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	383	0		29	10	S5617_383_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	383	0		29	10	S5617_383_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.65	18	18	18				39.79	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	383	0		29	10	S5617_383_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.74	46	46	46				50.84	45	45	45										46	46	46				45	45	45			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	383	0		29	10	S5617_383_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	384	0		29	10	S5617_384_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	384	0		29	10	S5617_384_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	6.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	6.00	20.00		20.00
S5617	384	0		29	10	S5617_384_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.07	18	18	18				37.57	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	384	0		29	10	S5617_384_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											57.00	47	47	47				48.93	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	384	0		29	10	S5617_384_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5617	385	0		29	10	S5617_385_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00
S5617	385	0		29	10	S5617_385_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					9.00	18.00	27.00											20.00	40.00	60.00				9.00	18.00	6.00				20.00				20.00			0.67	0.30		0.67	0.30	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	9.00	18.00	27.00	20.00	40.00	60.00	9.00	18.00	6.00	20.00		20.00
S5617	385	0		29	10	S5617_385_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.76	19	19	19				30.79	18	18	18										19	19	19				18	18	18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	385	0		29	10	S5617_385_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											51.56	49	49	49				40.20	48	48	48										49	49	49				48	48	48			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5617	385	0		29	10	S5617_385_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5715	001	0		29	10	S5715_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	1.00	2.00	3.00	10.00	20.00	30.00	1.00	2.00	3.00	10.00		10.00
S5715	001	0		29	10	S5715_001_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5715	001	0		29	10	S5715_001_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
S5715	001	0		29	10	S5715_001_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	001	0		29	10	S5715_001_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.50	34	34	34				98.08	31	31	31										34	34	34				31	31	31			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	001	0		29	10	S5715_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	003	0		29	10	S5715_003_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	1.00	2.00	3.00	10.00	20.00	30.00	1.00	2.00	3.00	10.00		10.00
S5715	003	0		29	10	S5715_003_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5715	003	0		29	10	S5715_003_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
S5715	003	0		29	10	S5715_003_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	003	0		29	10	S5715_003_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.55	31	31	31				93.73	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	003	0		29	10	S5715_003_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	005	0		29	10	S5715_005_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	1.00	2.00	3.00	10.00	20.00	30.00	1.00	2.00	3.00	10.00		10.00
S5715	005	0		29	10	S5715_005_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5715	005	0		29	10	S5715_005_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
S5715	005	0		29	10	S5715_005_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	005	0		29	10	S5715_005_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											97.31	31	31	31				92.49	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	005	0		29	10	S5715_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	010	0		29	10	S5715_010_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	1.00	2.00	3.00	10.00	20.00	30.00	1.00	2.00	3.00	10.00		10.00
S5715	010	0		29	10	S5715_010_0	5			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5715	010	0		29	10	S5715_010_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					8.00	16.00	24.00											20.00	40.00	60.00				8.00	16.00	24.00				20.00				20.00			0.67	0.27		0.67	0.27	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	8.00	16.00	24.00	20.00	40.00	60.00	8.00	16.00	24.00	20.00		20.00
S5715	010	0		29	10	S5715_010_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	010	0		29	10	S5715_010_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											97.80	37	37	37				99.19	33	33	33										37	37	37				33	33	33			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	010	0		29	10	S5715_010_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	012	0		29	10	S5715_012_0	5			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					1.00	2.00	3.00											15.00	30.00	45.00				1.00	2.00	3.00				15.00				15.00			0.50	0.03		0.50	0.03	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	1.00	2.00	3.00	15.00	30.00	45.00	1.00	2.00	3.00	15.00		15.00
S5715	012	0		29	10	S5715_012_0	5			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					6.00	12.00	18.00											20.00	40.00	60.00				6.00	12.00	18.00				20.00				20.00			0.67	0.20		0.67	0.20	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	6.00	12.00	18.00	20.00	40.00	60.00	6.00	12.00	18.00	20.00		20.00
S5715	012	0		29	10	S5715_012_0	5			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	012	0		29	10	S5715_012_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.56	47	47	47				85.11	47	47	47										47	47	47				47	47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	012	0		29	10	S5715_012_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	013	0		29	10	S5715_013_0	5			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					1.00	2.00	3.00											15.00	30.00	45.00				1.00	2.00	3.00				15.00				15.00			0.50	0.03		0.50	0.03	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	1.00	2.00	3.00	15.00	30.00	45.00	1.00	2.00	3.00	15.00		15.00
S5715	013	0		29	10	S5715_013_0	5			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	12.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	4.00	8.00	12.00	20.00	40.00	60.00	4.00	8.00	12.00	20.00		20.00
S5715	013	0		29	10	S5715_013_0	5			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					41.00	82.00	123.00											47.00	94.00	141.00				41.00	82.00	123.00				47.00				47.00			1.57	1.37		1.57	1.37	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	013	0		29	10	S5715_013_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											98.57	43	43	43				87.58	43	43	43										43	43	43				43	43	43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	013	0		29	10	S5715_013_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	014	0		29	10	S5715_014_0	5			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					1.00	2.00	3.00											9.00	18.00	27.00				1.00	2.00	3.00				9.00				9.00			0.30	0.03		0.30	0.03	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													9.00	18.00	27.00	1.00	2.00	3.00	9.00	18.00	27.00	1.00	2.00	3.00	9.00		9.00
S5715	014	0		29	10	S5715_014_0	5			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					3.00	6.00	9.00											13.00	26.00	39.00				3.00	6.00	9.00				13.00				13.00			0.43	0.10		0.43	0.10	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	3.00	6.00	9.00	13.00	26.00	39.00	3.00	6.00	9.00	13.00		13.00
S5715	014	0		29	10	S5715_014_0	5			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								40.00	80.00	120.00					35.00	70.00	105.00											40.00	80.00	120.00				35.00	70.00	105.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	014	0		29	10	S5715_014_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											94.57	50	50	50				83.79	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	014	0		29	10	S5715_014_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	015	0		29	10	S5715_015_0	5			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					1.00	2.00	3.00											10.00	20.00	30.00				1.00	2.00	3.00				10.00				10.00			0.33	0.03		0.33	0.03	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	1.00	2.00	3.00	10.00	20.00	30.00	1.00	2.00	3.00	10.00		10.00
S5715	015	0		29	10	S5715_015_0	5			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	39.00					3.00	6.00	9.00											13.00	26.00	39.00				3.00	6.00	9.00				13.00				13.00			0.43	0.10		0.43	0.10	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													13.00	26.00	39.00	3.00	6.00	9.00	13.00	26.00	39.00	3.00	6.00	9.00	13.00		13.00
S5715	015	0		29	10	S5715_015_0	5			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								40.00	80.00	120.00					35.00	70.00	105.00											40.00	80.00	120.00				35.00	70.00	105.00				40.00				40.00			1.33	1.17		1.33	1.17	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	015	0		29	10	S5715_015_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											96.61	50	50	50				75.66	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	015	0		29	10	S5715_015_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	018	0		29	10	S5715_018_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
S5715	018	0		29	10	S5715_018_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	15.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	5.00	10.00	15.00	20.00	40.00	60.00	5.00	10.00	15.00	20.00		20.00
S5715	018	0		29	10	S5715_018_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					46.00	92.00	138.00											47.00	94.00	141.00				46.00	92.00	138.00				47.00				47.00			1.57	1.53		1.57	1.53	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	018	0		29	10	S5715_018_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											97.57	40	40	40				97.31	34	34	34										40	40	40				34	34	34			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	018	0		29	10	S5715_018_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	019	0		29	10	S5715_019_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
S5715	019	0		29	10	S5715_019_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					7.00	14.00	21.00											20.00	40.00	60.00				7.00	14.00	21.00				20.00				20.00			0.67	0.23		0.67	0.23	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	7.00	14.00	21.00	20.00	40.00	60.00	7.00	14.00	21.00	20.00		20.00
S5715	019	0		29	10	S5715_019_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					46.00	92.00	138.00											47.00	94.00	141.00				46.00	92.00	138.00				47.00				47.00			1.57	1.53		1.57	1.53	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	019	0		29	10	S5715_019_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											96.95	38	38	38				93.66	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	019	0		29	10	S5715_019_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	020	0		29	10	S5715_020_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
S5715	020	0		29	10	S5715_020_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	9.00				20.00				20.00			0.67	0.10		0.67	0.10	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	3.00	6.00	9.00	20.00	40.00	60.00	3.00	6.00	9.00	20.00		20.00
S5715	020	0		29	10	S5715_020_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					46.00	92.00	138.00											47.00	94.00	141.00				46.00	92.00	138.00				47.00				47.00			1.57	1.53		1.57	1.53	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	020	0		29	10	S5715_020_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											90.40	50	50	50				89.59	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	020	0		29	10	S5715_020_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5715	021	0		29	10	S5715_021_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	0.00	0.00	0.00	15.00	30.00	45.00	0.00	0.00	0.00	15.00		15.00
S5715	021	0		29	10	S5715_021_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00											20.00	40.00	60.00				3.00	6.00	9.00				20.00				20.00			0.67	0.10		0.67	0.10	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	3.00	6.00	9.00	20.00	40.00	60.00	3.00	6.00	9.00	20.00		20.00
S5715	021	0		29	10	S5715_021_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					46.00	92.00	138.00											47.00	94.00	141.00				46.00	92.00	138.00				47.00				47.00			1.57	1.53		1.57	1.53	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	021	0		29	10	S5715_021_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											89.39	50	50	50				83.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5715	021	0		29	10	S5715_021_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5726	013	0		29	10	S5726_013_0	3			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								3.00	6.00	9.00					1.00	2.00	3.00					1.00	2.00	3.00																3.00				3.00			0.10	0.03	0.03			0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5726	013	0		29	10	S5726_013_0	3			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					3.00	6.00	9.00					3.00	6.00	9.00																5.00				5.00			0.17	0.10	0.10			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5726	013	0		29	10	S5726_013_0	3			Preferred Brand	3	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											29.20	20	20	20				29.20	20	20	20				20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5726	013	0		29	10	S5726_013_0	3			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.44	41	41	41				63.84	40	40	40				40	40	40															41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5726	013	0		29	10	S5726_013_0	3			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		34												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5726	014	0		29	10	S5726_014_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								19.00	38.00	57.00					1.00	2.00	3.00					1.00	2.00	3.00																19.00				19.00			0.63	0.03	0.03			0.56	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5726	014	0		29	10	S5726_014_0	4			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					4.00	8.00	12.00					4.00	8.00	12.00																20.00				20.00			0.67	0.13	0.13			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5726	014	0		29	10	S5726_014_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	141.00																47.00				47.00			1.57	1.57	1.57			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5726	014	0		29	10	S5726_014_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											48.66	50	50	50				48.66	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5726	014	0		29	10	S5726_014_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5743	001	0		29	10	S5743_001_0	2			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					7.00	14.00	21.00											15.00	30.00	45.00				7.00	14.00	21.00				15.00				15.00			0.50	0.23		0.50	0.23	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	45.00	7.00	14.00	21.00	15.00	30.00	45.00	7.00	14.00	21.00	15.00		15.00
S5743	001	0		29	10	S5743_001_0	2			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					13.00	26.00	39.00											20.00	40.00	60.00				13.00	26.00	39.00				20.00				20.00			0.67	0.43		0.67	0.43	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00	13.00	26.00	39.00	20.00	40.00	60.00	13.00	26.00	39.00	20.00		20.00
S5743	001	0		29	10	S5743_001_0	2			Preferred Brand	3	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					43.00	86.00	129.00											47.00	94.00	141.00				43.00	86.00	129.00				47.00				47.00			1.57	1.43		1.57	1.43	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5743	001	0		29	10	S5743_001_0	2			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											92.75	50	50	50				76.83	45	45	45										50	50	50				45	45	45			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5743	001	0		29	10	S5743_001_0	2			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31											1182.22	25						1279.81	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5743	004	0		29	10	S5743_004_0	2			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	30.00	0.00	0.00	0.00	15.00	30.00	30.00	0.00	0.00	0.00	15.00		15.00
S5743	004	0		29	10	S5743_004_0	2			Preferred Generic	4	01	1	2	1	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5743	004	0		29	10	S5743_004_0	2			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	40.00	0.00	0.00	0.00	20.00	40.00	40.00	0.00	0.00	0.00	20.00		20.00
S5743	004	0		29	10	S5743_004_0	2			Generic	4	01	1	2	2	3		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	40.00					0.00	0.00	0.00											20.00	40.00	40.00				0.00	0.00	0.00				20.00				20.00			0.67	0.00		0.67	0.00	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5743	004	0		29	10	S5743_004_0	2			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											48.50	25	25	25				36.50	20	20	20										25	25	25				20	20	20			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5743	004	0		29	10	S5743_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											86.19	45	45	45				70.68	40	40	40										45	45	45				40	40	40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5743	004	0		29	10	S5743_004_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1033.67	33						1069.93	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5743	008	0		29	10	S5743_008_0	2			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	24.00					2.00	4.00	4.00											12.00	24.00	24.00				2.00	4.00	4.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													12.00	24.00	24.00	2.00	4.00	4.00	12.00	24.00	24.00	2.00	4.00	4.00	12.00		12.00
S5743	008	0		29	10	S5743_008_0	2			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	30.00					6.00	12.00	12.00											15.00	30.00	30.00				6.00	12.00	12.00				15.00				15.00			0.50	0.20		0.50	0.20	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													15.00	30.00	30.00	6.00	12.00	12.00	15.00	30.00	30.00	6.00	12.00	12.00	15.00		15.00
S5743	008	0		29	10	S5743_008_0	2			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5743	008	0		29	10	S5743_008_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											83.99	50	50	50				72.89	46	46	46										50	50	50				46	46	46			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5743	008	0		29	10	S5743_008_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1666.66	25						1694.99	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5795	002	0		29	10	S5795_002_0	1			Preferred Generic	4	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5795	002	0		29	10	S5795_002_0	1			Preferred Generic	4	11	1	2	1	3	110		01	110		1	30		100				1	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5795	002	0		29	10	S5795_002_0	1			Generic	4	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	5.00		15.00																			5.00		15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5795	002	0		29	10	S5795_002_0	1			Generic	4	11	1	2	2	3	110		01	110		1	30		100				1	2	30		100				30		31	5.00		15.00																			5.00		15.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5795	002	0		29	10	S5795_002_0	1			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5795	002	0		29	10	S5795_002_0	1			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		100				1	2	30		100				30		31	100.00		300.00																			100.00		300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5795	002	0		29	10	S5795_002_0	1			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				888.16	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
S5795	003	0		29	10	S5795_003_0	1			Preferred Generic	3	11	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	6.00		18.00																			6.00		18.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5795	003	0		29	10	S5795_003_0	1			Generic	3	11	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5795	003	0		29	10	S5795_003_0	1			Preferred Brand	3	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	45.00		135.00																			45.00		135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5795	003	0		29	10	S5795_003_0	1			Non-Preferred Drug	3	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				87.99	45		45																		45		45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5795	003	0		29	10	S5795_003_0	1			Specialty Tier	3	11	1	1	5	1	010		01	010		1	30								30						30		31				1151.74	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
S5805	001	0		29	10	S5805_001_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5805	001	0		29	10	S5805_001_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5805	001	0		29	10	S5805_001_0	3			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5805	001	0		29	10	S5805_001_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5805	001	0		29	10	S5805_001_0	3			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											66.00	45		45				52.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5805	001	0		29	10	S5805_001_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											550.00	33						577.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	001	0		29	10	S5820_001_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	001	0		29	10	S5820_001_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	001	0		29	10	S5820_001_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	001	0		29	10	S5820_001_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	001	0		29	10	S5820_001_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	45		45				42.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	001	0		29	10	S5820_001_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											429.00	33						657.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	002	0		29	10	S5820_002_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	002	0		29	10	S5820_002_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	002	0		29	10	S5820_002_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	002	0		29	10	S5820_002_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	002	0		29	10	S5820_002_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											59.00	45		45				50.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	002	0		29	10	S5820_002_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											449.00	33						516.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	003	0		29	10	S5820_003_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	003	0		29	10	S5820_003_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	003	0		29	10	S5820_003_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	003	0		29	10	S5820_003_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	003	0		29	10	S5820_003_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											63.00	45		45				49.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	003	0		29	10	S5820_003_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											480.00	33						527.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	004	0		29	10	S5820_004_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	004	0		29	10	S5820_004_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	004	0		29	10	S5820_004_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	004	0		29	10	S5820_004_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	004	0		29	10	S5820_004_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											61.00	45		45				48.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	004	0		29	10	S5820_004_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											601.00	33						673.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	005	0		29	10	S5820_005_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	005	0		29	10	S5820_005_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	005	0		29	10	S5820_005_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	005	0		29	10	S5820_005_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	005	0		29	10	S5820_005_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											56.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	005	0		29	10	S5820_005_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											399.00	33						453.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	006	0		29	10	S5820_006_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	006	0		29	10	S5820_006_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	006	0		29	10	S5820_006_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	006	0		29	10	S5820_006_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	006	0		29	10	S5820_006_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											54.00	45		45				44.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	006	0		29	10	S5820_006_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											456.00	33						476.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	007	0		29	10	S5820_007_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	007	0		29	10	S5820_007_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	007	0		29	10	S5820_007_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	007	0		29	10	S5820_007_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	007	0		29	10	S5820_007_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											58.00	45		45				46.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	007	0		29	10	S5820_007_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											433.00	33						423.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	008	0		29	10	S5820_008_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	008	0		29	10	S5820_008_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	008	0		29	10	S5820_008_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	008	0		29	10	S5820_008_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	008	0		29	10	S5820_008_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											66.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	008	0		29	10	S5820_008_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											434.00	33						462.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	009	0		29	10	S5820_009_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	009	0		29	10	S5820_009_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	009	0		29	10	S5820_009_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	009	0		29	10	S5820_009_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	009	0		29	10	S5820_009_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											57.00	45		45				48.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	009	0		29	10	S5820_009_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											462.00	33						698.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	010	0		29	10	S5820_010_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	010	0		29	10	S5820_010_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	010	0		29	10	S5820_010_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	010	0		29	10	S5820_010_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	010	0		29	10	S5820_010_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											61.00	45		45				48.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	010	0		29	10	S5820_010_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											483.00	33						456.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	011	0		29	10	S5820_011_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	011	0		29	10	S5820_011_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	011	0		29	10	S5820_011_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	011	0		29	10	S5820_011_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	011	0		29	10	S5820_011_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											57.00	45		45				48.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	011	0		29	10	S5820_011_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											433.00	33						551.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	012	0		29	10	S5820_012_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	012	0		29	10	S5820_012_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	012	0		29	10	S5820_012_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	012	0		29	10	S5820_012_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	012	0		29	10	S5820_012_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											53.00	45		45				43.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	012	0		29	10	S5820_012_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											420.00	33						588.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	013	0		29	10	S5820_013_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	013	0		29	10	S5820_013_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	013	0		29	10	S5820_013_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	013	0		29	10	S5820_013_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	013	0		29	10	S5820_013_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											52.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	013	0		29	10	S5820_013_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											373.00	33						512.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	014	0		29	10	S5820_014_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	014	0		29	10	S5820_014_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	014	0		29	10	S5820_014_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	014	0		29	10	S5820_014_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	014	0		29	10	S5820_014_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	014	0		29	10	S5820_014_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											436.00	33						478.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	015	0		29	10	S5820_015_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	015	0		29	10	S5820_015_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	015	0		29	10	S5820_015_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	015	0		29	10	S5820_015_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	015	0		29	10	S5820_015_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											56.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	015	0		29	10	S5820_015_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											504.00	33						293.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	016	0		29	10	S5820_016_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	016	0		29	10	S5820_016_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	016	0		29	10	S5820_016_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	016	0		29	10	S5820_016_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	016	0		29	10	S5820_016_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	016	0		29	10	S5820_016_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											408.00	33						610.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	017	0		29	10	S5820_017_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	017	0		29	10	S5820_017_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	017	0		29	10	S5820_017_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	017	0		29	10	S5820_017_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	017	0		29	10	S5820_017_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											56.00	45		45				45.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	017	0		29	10	S5820_017_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											528.00	33						337.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	018	0		29	10	S5820_018_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	018	0		29	10	S5820_018_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	018	0		29	10	S5820_018_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	018	0		29	10	S5820_018_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	018	0		29	10	S5820_018_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											59.00	45		45				40.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	018	0		29	10	S5820_018_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											521.00	33						443.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	019	0		29	10	S5820_019_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	019	0		29	10	S5820_019_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	019	0		29	10	S5820_019_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	019	0		29	10	S5820_019_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	019	0		29	10	S5820_019_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	45		45				44.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	019	0		29	10	S5820_019_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											308.00	33						485.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	020	0		29	10	S5820_020_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	020	0		29	10	S5820_020_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	020	0		29	10	S5820_020_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	020	0		29	10	S5820_020_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	020	0		29	10	S5820_020_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											59.00	45		45				44.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	020	0		29	10	S5820_020_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											590.00	33						417.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	021	0		29	10	S5820_021_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	021	0		29	10	S5820_021_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	021	0		29	10	S5820_021_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	021	0		29	10	S5820_021_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	021	0		29	10	S5820_021_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											61.00	45		45				49.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	021	0		29	10	S5820_021_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											478.00	33						446.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	022	0		29	10	S5820_022_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	022	0		29	10	S5820_022_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	022	0		29	10	S5820_022_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	022	0		29	10	S5820_022_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	022	0		29	10	S5820_022_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											68.00	45		45				47.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	022	0		29	10	S5820_022_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											457.00	33						385.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	023	0		29	10	S5820_023_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	023	0		29	10	S5820_023_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	023	0		29	10	S5820_023_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	023	0		29	10	S5820_023_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	023	0		29	10	S5820_023_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											63.00	45		45				47.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	023	0		29	10	S5820_023_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											604.00	33						584.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	024	0		29	10	S5820_024_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	024	0		29	10	S5820_024_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	024	0		29	10	S5820_024_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	024	0		29	10	S5820_024_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	024	0		29	10	S5820_024_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											59.00	45		45				46.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	024	0		29	10	S5820_024_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											389.00	33						578.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	025	0		29	10	S5820_025_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	025	0		29	10	S5820_025_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	025	0		29	10	S5820_025_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	025	0		29	10	S5820_025_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	025	0		29	10	S5820_025_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	45		45				48.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	025	0		29	10	S5820_025_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											652.00	33						366.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	026	0		29	10	S5820_026_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	026	0		29	10	S5820_026_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	026	0		29	10	S5820_026_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	026	0		29	10	S5820_026_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	026	0		29	10	S5820_026_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											62.00	45		45				56.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	026	0		29	10	S5820_026_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											475.00	33						462.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	027	0		29	10	S5820_027_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	027	0		29	10	S5820_027_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	027	0		29	10	S5820_027_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	027	0		29	10	S5820_027_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	027	0		29	10	S5820_027_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											58.00	45		45				51.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	027	0		29	10	S5820_027_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											530.00	33						434.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	028	0		29	10	S5820_028_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	028	0		29	10	S5820_028_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	028	0		29	10	S5820_028_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	028	0		29	10	S5820_028_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	028	0		29	10	S5820_028_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											61.00	45		45				50.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	028	0		29	10	S5820_028_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											490.00	33						457.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	029	0		29	10	S5820_029_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	029	0		29	10	S5820_029_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	029	0		29	10	S5820_029_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	029	0		29	10	S5820_029_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	029	0		29	10	S5820_029_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	45		45				43.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	029	0		29	10	S5820_029_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											453.00	33						545.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	030	0		29	10	S5820_030_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	030	0		29	10	S5820_030_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	030	0		29	10	S5820_030_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	030	0		29	10	S5820_030_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	030	0		29	10	S5820_030_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											57.00	45		45				47.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	030	0		29	10	S5820_030_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											547.00	33						829.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	031	0		29	10	S5820_031_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	031	0		29	10	S5820_031_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	031	0		29	10	S5820_031_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	031	0		29	10	S5820_031_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	031	0		29	10	S5820_031_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											66.00	45		45				52.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	031	0		29	10	S5820_031_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											530.00	33						564.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	032	0		29	10	S5820_032_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	032	0		29	10	S5820_032_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	032	0		29	10	S5820_032_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	032	0		29	10	S5820_032_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	032	0		29	10	S5820_032_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											63.00	45		45				60.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	032	0		29	10	S5820_032_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											430.00	33						703.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	033	0		29	10	S5820_033_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								15.00		45.00					7.00		21.00													45.00						0.00				15.00				15.00			0.50	0.23				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	033	0		29	10	S5820_033_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	033	0		29	10	S5820_033_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					12.00		36.00													60.00						0.00				20.00				20.00			0.66	0.40				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5820	033	0		29	10	S5820_033_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						126.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	033	0		29	10	S5820_033_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											62.00	45		45				54.00	40		40												45						40			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	033	0		29	10	S5820_033_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											405.00	33						639.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	035	0		29	10	S5820_035_0	2			Preferred Generic	2	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	19.00		57.00																					57.00																19.00				19.00		0.63						0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	035	0		29	10	S5820_035_0	2			Generic	2	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	20.00		60.00																					60.00																20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	035	0		29	10	S5820_035_0	2			Preferred Brand	2	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	47.00		141.00																					141.00																47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
S5820	035	0		29	10	S5820_035_0	2			Non-Preferred Drug	2	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		31				52.00	50		50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
S5820	035	0		29	10	S5820_035_0	2			Specialty Tier	2	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				352.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	037	0		29	10	S5820_037_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								7.00		21.00					6.00		18.00													21.00						18.00				7.00				7.00			0.23	0.20				0.22	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	037	0		29	10	S5820_037_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								19.00		57.00					14.00		42.00													57.00						42.00				19.00				19.00			0.63	0.46				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	037	0		29	10	S5820_037_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	037	0		29	10	S5820_037_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											55.00	50		50				65.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5820	037	0		29	10	S5820_037_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											102.00	25						402.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	038	0		29	10	S5820_038_0	2			Preferred Generic	2	01	1	2	1	1	110		01	100		1	30		90				2	2			90				30		31	19.00		57.00																					57.00																19.00				19.00		0.63						0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	038	0		29	10	S5820_038_0	2			Generic	2	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		31	20.00		60.00																					60.00																20.00				20.00		0.66						0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5820	038	0		29	10	S5820_038_0	2			Preferred Brand	2	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		31	47.00		141.00																					141.00																47.00				47.00		1.56						1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
S5820	038	0		29	10	S5820_038_0	2			Non-Preferred Drug	2	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		31				60.00	50		50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00						105.00				35.00		35.00
S5820	038	0		29	10	S5820_038_0	2			Specialty Tier	2	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				147.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5884	101	0		29	10	S5884_101_0	7			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	101	0		29	10	S5884_101_0	7			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	101	0		29	10	S5884_101_0	7			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	101	0		29	10	S5884_101_0	7			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				85.00	39		39																								39		39				39		30			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	101	0		29	10	S5884_101_0	7			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	102	0		29	10	S5884_102_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	102	0		29	10	S5884_102_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	102	0		29	10	S5884_102_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				48.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	102	0		29	10	S5884_102_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	41		41																								41		41				41		30			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	102	0		29	10	S5884_102_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	103	0		29	10	S5884_103_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	103	0		29	10	S5884_103_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	103	0		29	10	S5884_103_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				51.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	103	0		29	10	S5884_103_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	39		39																								39		39				39		30			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	103	0		29	10	S5884_103_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	104	0		29	10	S5884_104_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	104	0		29	10	S5884_104_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	104	0		29	10	S5884_104_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	104	0		29	10	S5884_104_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				97.00	42		42																								42		42				42		30			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	104	0		29	10	S5884_104_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	105	0		29	10	S5884_105_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	105	0		29	10	S5884_105_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	105	0		29	10	S5884_105_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	105	0		29	10	S5884_105_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	47		47																								47		47				47		30			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	105	0		29	10	S5884_105_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	106	0		29	10	S5884_106_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	106	0		29	10	S5884_106_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	106	0		29	10	S5884_106_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				43.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	106	0		29	10	S5884_106_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	106	0		29	10	S5884_106_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	107	0		29	10	S5884_107_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	107	0		29	10	S5884_107_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1		1
S5884	107	0		29	10	S5884_107_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35		35
S5884	107	0		29	10	S5884_107_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				73.00	42		42																								42		42				42		30			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35		35
S5884	107	0		29	10	S5884_107_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35		35
S5884	108	0		29	10	S5884_108_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	108	0		29	10	S5884_108_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	108	0		29	10	S5884_108_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	108	0		29	10	S5884_108_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	108	0		29	10	S5884_108_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	109	0		29	10	S5884_109_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	109	0		29	10	S5884_109_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1		1
S5884	109	0		29	10	S5884_109_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35		35
S5884	109	0		29	10	S5884_109_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				75.00	41		41																								41		41				41		30			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35		35
S5884	109	0		29	10	S5884_109_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35		35
S5884	110	0		29	10	S5884_110_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	110	0		29	10	S5884_110_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	110	0		29	10	S5884_110_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				51.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	110	0		29	10	S5884_110_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				95.00	40		40																								40		40				40		30			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	110	0		29	10	S5884_110_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	111	0		29	10	S5884_111_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	111	0		29	10	S5884_111_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	111	0		29	10	S5884_111_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				47.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	111	0		29	10	S5884_111_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				93.00	36		36																								36		36				36		30			36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	111	0		29	10	S5884_111_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	112	0		29	10	S5884_112_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	112	0		29	10	S5884_112_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1		1
S5884	112	0		29	10	S5884_112_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				50.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35		35
S5884	112	0		29	10	S5884_112_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	36		36																								36		36				36		30			36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35		35
S5884	112	0		29	10	S5884_112_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35		35
S5884	113	0		29	10	S5884_113_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	113	0		29	10	S5884_113_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	113	0		29	10	S5884_113_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				49.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	113	0		29	10	S5884_113_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	40		40																								40		40				40		30			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	113	0		29	10	S5884_113_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	114	0		29	10	S5884_114_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	114	0		29	10	S5884_114_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	114	0		29	10	S5884_114_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	114	0		29	10	S5884_114_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				91.00	43		43																								43		43				43		30			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	114	0		29	10	S5884_114_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	115	0		29	10	S5884_115_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	3.00		9.00																									3.00		9.00				3.00		0.00				3.00				3.00		0.10				0.10	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		9.00				3.00		9.00	3.00		0.00	3.00		3.00
S5884	115	0		29	10	S5884_115_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	5.00		15.00																									5.00		15.00				5.00		0.00				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													5.00		15.00				5.00		15.00	5.00		0.00	5.00		5.00
S5884	115	0		29	10	S5884_115_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	21		21																								21		21				21		15			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	115	0		29	10	S5884_115_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				89.00	50		50																								50		50				50		30			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	115	0		29	10	S5884_115_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	116	0		29	10	S5884_116_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									2.00		6.00				2.00		0.00				2.00				2.00		0.07				0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				2.00		6.00	2.00		0.00	2.00		2.00
S5884	116	0		29	10	S5884_116_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	3.00		9.00																									3.00		9.00				3.00		0.00				3.00				3.00		0.10				0.10	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		9.00				3.00		9.00	3.00		0.00	3.00		3.00
S5884	116	0		29	10	S5884_116_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				50.00	21		21																								21		21				21		15			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	116	0		29	10	S5884_116_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	43		43																								43		43				43		30			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	116	0		29	10	S5884_116_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	131	0		29	10	S5884_131_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	131	0		29	10	S5884_131_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	131	0		29	10	S5884_131_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				47.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	131	0		29	10	S5884_131_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				81.00	41		41																								41		41				41		30			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	131	0		29	10	S5884_131_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	132	0		29	10	S5884_132_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	132	0		29	10	S5884_132_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	132	0		29	10	S5884_132_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	132	0		29	10	S5884_132_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				96.00	41		41																								41		41				41		30			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	132	0		29	10	S5884_132_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	133	0		29	10	S5884_133_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	133	0		29	10	S5884_133_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	133	0		29	10	S5884_133_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	133	0		29	10	S5884_133_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	37		37																								37		37				37		30			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	133	0		29	10	S5884_133_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	134	0		29	10	S5884_134_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	134	0		29	10	S5884_134_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									2.00		6.00				2.00		0.00				2.00				2.00		0.07				0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				2.00		6.00	2.00		0.00	2.00		2.00
S5884	134	0		29	10	S5884_134_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				43.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	134	0		29	10	S5884_134_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				90.00	50		50																								50		50				50		30			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	134	0		29	10	S5884_134_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	135	0		29	10	S5884_135_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	135	0		29	10	S5884_135_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	135	0		29	10	S5884_135_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	135	0		29	10	S5884_135_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				91.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	135	0		29	10	S5884_135_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	136	0		29	10	S5884_136_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	136	0		29	10	S5884_136_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	136	0		29	10	S5884_136_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				47.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	136	0		29	10	S5884_136_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				87.00	37		37																								37		37				37		30			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	136	0		29	10	S5884_136_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	137	0		29	10	S5884_137_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	137	0		29	10	S5884_137_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									2.00		6.00				2.00		0.00				2.00				2.00		0.07				0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				2.00		6.00	2.00		0.00	2.00		2.00
S5884	137	0		29	10	S5884_137_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	25		25																								25		25				25		15			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	137	0		29	10	S5884_137_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				81.00	50		50																								50		50				50		30			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	137	0		29	10	S5884_137_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	138	0		29	10	S5884_138_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	138	0		29	10	S5884_138_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	138	0		29	10	S5884_138_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				41.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	138	0		29	10	S5884_138_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				86.00	50		50																								50		50				50		30			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	138	0		29	10	S5884_138_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	139	0		29	10	S5884_139_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	139	0		29	10	S5884_139_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	139	0		29	10	S5884_139_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				43.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	139	0		29	10	S5884_139_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				92.00	40		40																								40		40				40		30			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	139	0		29	10	S5884_139_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	140	0		29	10	S5884_140_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	140	0		29	10	S5884_140_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	140	0		29	10	S5884_140_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				37.00	24		24																								24		24				24		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	140	0		29	10	S5884_140_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				72.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	140	0		29	10	S5884_140_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	141	0		29	10	S5884_141_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	141	0		29	10	S5884_141_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	141	0		29	10	S5884_141_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				40.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	141	0		29	10	S5884_141_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	44		44																								44		44				44		30			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	141	0		29	10	S5884_141_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	142	0		29	10	S5884_142_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	142	0		29	10	S5884_142_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	142	0		29	10	S5884_142_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				45.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	142	0		29	10	S5884_142_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	41		41																								41		41				41		30			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	142	0		29	10	S5884_142_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	143	0		29	10	S5884_143_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	143	0		29	10	S5884_143_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	143	0		29	10	S5884_143_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	25		25																								25		25				25		15			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	143	0		29	10	S5884_143_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				75.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	143	0		29	10	S5884_143_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	144	0		29	10	S5884_144_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	144	0		29	10	S5884_144_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	2.00		6.00																									2.00		6.00				2.00		0.00				2.00				2.00		0.07				0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				2.00		6.00	2.00		0.00	2.00		2.00
S5884	144	0		29	10	S5884_144_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	144	0		29	10	S5884_144_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				99.00	35		35																								35		35				35		30			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	144	0		29	10	S5884_144_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	145	0		29	10	S5884_145_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	145	0		29	10	S5884_145_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	145	0		29	10	S5884_145_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				40.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	145	0		29	10	S5884_145_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				82.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	145	0		29	10	S5884_145_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	146	0		29	10	S5884_146_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	2.00		6.00																									2.00		6.00				2.00		0.00				2.00				2.00		0.07				0.07	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													2.00		6.00				2.00		6.00	2.00		0.00	2.00		2.00
S5884	146	0		29	10	S5884_146_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	3.00		9.00																									3.00		9.00				3.00		0.00				3.00				3.00		0.10				0.10	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00		9.00				3.00		9.00	3.00		0.00	3.00		3.00
S5884	146	0		29	10	S5884_146_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				50.00	22		22																								22		22				22		15			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	146	0		29	10	S5884_146_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	38		38																								38		38				38		30			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	146	0		29	10	S5884_146_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	147	0		29	10	S5884_147_0	1			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00
S5884	147	0		29	10	S5884_147_0	1			Generic	2	11	1	2	2	1	110		01		110	1	30		90				2	2				30		90	30		31	1.00		3.00																									1.00		3.00				1.00		0.00				1.00				1.00		0.03				0.03	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													1.00		3.00				1.00		3.00	1.00		0.00	1.00		1.00
S5884	147	0		29	10	S5884_147_0	1			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				41.00	23		23																								23		23				23		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	147	0		29	10	S5884_147_0	1			Non-Preferred Drug	2	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				100.00	37		37																								37		37				37		30			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00
S5884	147	0		29	10	S5884_147_0	1			Specialty Tier	2	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00			35.00			35.00		35.00
S5884	148	0		29	10	S5884_148_0	3			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	148	0		29	10	S5884_148_0	3			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	148	0		29	10	S5884_148_0	3			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	148	0		29	10	S5884_148_0	3			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	148	0		29	10	S5884_148_0	3			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	148	0		29	10	S5884_148_0	3			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											89.00	50		50				87.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	148	0		29	10	S5884_148_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	148	0		29	10	S5884_148_0	3			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	148	0		29	10	S5884_148_0	3			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	149	0		29	10	S5884_149_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	149	0		29	10	S5884_149_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	149	0		29	10	S5884_149_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	149	0		29	10	S5884_149_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	149	0		29	10	S5884_149_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	149	0		29	10	S5884_149_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											82.00	50		50				80.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	149	0		29	10	S5884_149_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	149	0		29	10	S5884_149_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	149	0		29	10	S5884_149_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	150	0		29	10	S5884_150_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	150	0		29	10	S5884_150_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	150	0		29	10	S5884_150_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	150	0		29	10	S5884_150_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	150	0		29	10	S5884_150_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	150	0		29	10	S5884_150_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											88.00	50		50				87.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	150	0		29	10	S5884_150_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	150	0		29	10	S5884_150_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	150	0		29	10	S5884_150_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	151	0		29	10	S5884_151_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	151	0		29	10	S5884_151_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	151	0		29	10	S5884_151_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	151	0		29	10	S5884_151_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	151	0		29	10	S5884_151_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	151	0		29	10	S5884_151_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											62.00	49		49				61.00	48		48										49		49				48		48			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	151	0		29	10	S5884_151_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	151	0		29	10	S5884_151_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	151	0		29	10	S5884_151_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	152	0		29	10	S5884_152_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	152	0		29	10	S5884_152_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	152	0		29	10	S5884_152_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	152	0		29	10	S5884_152_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	152	0		29	10	S5884_152_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	152	0		29	10	S5884_152_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											74.00	50		50				73.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	152	0		29	10	S5884_152_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	152	0		29	10	S5884_152_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	152	0		29	10	S5884_152_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	153	0		29	10	S5884_153_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	153	0		29	10	S5884_153_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	153	0		29	10	S5884_153_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	153	0		29	10	S5884_153_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	153	0		29	10	S5884_153_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	153	0		29	10	S5884_153_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											88.00	50		50				86.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	153	0		29	10	S5884_153_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	153	0		29	10	S5884_153_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	153	0		29	10	S5884_153_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	154	0		29	10	S5884_154_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	154	0		29	10	S5884_154_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	154	0		29	10	S5884_154_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	154	0		29	10	S5884_154_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	154	0		29	10	S5884_154_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	154	0		29	10	S5884_154_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											61.00	50		50				59.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	154	0		29	10	S5884_154_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	154	0		29	10	S5884_154_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	154	0		29	10	S5884_154_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	155	0		29	10	S5884_155_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	155	0		29	10	S5884_155_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	155	0		29	10	S5884_155_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	155	0		29	10	S5884_155_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	155	0		29	10	S5884_155_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	155	0		29	10	S5884_155_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											88.00	50		50				87.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	155	0		29	10	S5884_155_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	155	0		29	10	S5884_155_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	155	0		29	10	S5884_155_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	156	0		29	10	S5884_156_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	156	0		29	10	S5884_156_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	156	0		29	10	S5884_156_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	156	0		29	10	S5884_156_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	156	0		29	10	S5884_156_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	156	0		29	10	S5884_156_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											91.00	50		50				89.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	156	0		29	10	S5884_156_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	156	0		29	10	S5884_156_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	156	0		29	10	S5884_156_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	157	0		29	10	S5884_157_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	157	0		29	10	S5884_157_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	157	0		29	10	S5884_157_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	157	0		29	10	S5884_157_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	157	0		29	10	S5884_157_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	157	0		29	10	S5884_157_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											61.00	50		50				60.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	157	0		29	10	S5884_157_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	157	0		29	10	S5884_157_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	157	0		29	10	S5884_157_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	158	0		29	10	S5884_158_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	158	0		29	10	S5884_158_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	158	0		29	10	S5884_158_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	158	0		29	10	S5884_158_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	158	0		29	10	S5884_158_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	158	0		29	10	S5884_158_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											88.00	50		50				86.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	158	0		29	10	S5884_158_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	158	0		29	10	S5884_158_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	158	0		29	10	S5884_158_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	159	0		29	10	S5884_159_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	159	0		29	10	S5884_159_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	159	0		29	10	S5884_159_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	159	0		29	10	S5884_159_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	159	0		29	10	S5884_159_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	159	0		29	10	S5884_159_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											58.00	50		50				57.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	159	0		29	10	S5884_159_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	159	0		29	10	S5884_159_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	159	0		29	10	S5884_159_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	160	0		29	10	S5884_160_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	160	0		29	10	S5884_160_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	160	0		29	10	S5884_160_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	160	0		29	10	S5884_160_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	160	0		29	10	S5884_160_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	160	0		29	10	S5884_160_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	33		33				100.00	33		33										33		33				33		33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	160	0		29	10	S5884_160_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	160	0		29	10	S5884_160_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	160	0		29	10	S5884_160_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	161	0		29	10	S5884_161_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	161	0		29	10	S5884_161_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	161	0		29	10	S5884_161_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	161	0		29	10	S5884_161_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	161	0		29	10	S5884_161_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	161	0		29	10	S5884_161_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											60.00	50		50				58.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	161	0		29	10	S5884_161_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	161	0		29	10	S5884_161_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	161	0		29	10	S5884_161_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	162	0		29	10	S5884_162_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	162	0		29	10	S5884_162_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	162	0		29	10	S5884_162_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	162	0		29	10	S5884_162_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	162	0		29	10	S5884_162_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	162	0		29	10	S5884_162_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											81.00	50		50				79.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	162	0		29	10	S5884_162_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	162	0		29	10	S5884_162_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	162	0		29	10	S5884_162_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	163	0		29	10	S5884_163_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	163	0		29	10	S5884_163_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	163	0		29	10	S5884_163_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	163	0		29	10	S5884_163_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	163	0		29	10	S5884_163_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	163	0		29	10	S5884_163_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											75.00	50		50				73.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	163	0		29	10	S5884_163_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	163	0		29	10	S5884_163_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	163	0		29	10	S5884_163_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	164	0		29	10	S5884_164_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	164	0		29	10	S5884_164_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	164	0		29	10	S5884_164_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	164	0		29	10	S5884_164_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	164	0		29	10	S5884_164_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	164	0		29	10	S5884_164_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											56.00	50		50				54.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	164	0		29	10	S5884_164_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	164	0		29	10	S5884_164_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	164	0		29	10	S5884_164_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	165	0		29	10	S5884_165_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	165	0		29	10	S5884_165_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	165	0		29	10	S5884_165_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	165	0		29	10	S5884_165_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	165	0		29	10	S5884_165_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	165	0		29	10	S5884_165_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											73.00	50		50				71.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	165	0		29	10	S5884_165_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	165	0		29	10	S5884_165_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	165	0		29	10	S5884_165_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	166	0		29	10	S5884_166_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	166	0		29	10	S5884_166_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	166	0		29	10	S5884_166_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	166	0		29	10	S5884_166_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	166	0		29	10	S5884_166_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	166	0		29	10	S5884_166_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											81.00	50		50				79.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	166	0		29	10	S5884_166_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	166	0		29	10	S5884_166_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	166	0		29	10	S5884_166_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	167	0		29	10	S5884_167_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	167	0		29	10	S5884_167_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	167	0		29	10	S5884_167_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	167	0		29	10	S5884_167_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	167	0		29	10	S5884_167_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	167	0		29	10	S5884_167_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											75.00	50		50				74.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	167	0		29	10	S5884_167_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	167	0		29	10	S5884_167_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	167	0		29	10	S5884_167_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	168	0		29	10	S5884_168_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	168	0		29	10	S5884_168_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	168	0		29	10	S5884_168_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	168	0		29	10	S5884_168_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	168	0		29	10	S5884_168_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	168	0		29	10	S5884_168_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											62.00	50		50				61.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	168	0		29	10	S5884_168_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	168	0		29	10	S5884_168_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	168	0		29	10	S5884_168_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	169	0		29	10	S5884_169_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	169	0		29	10	S5884_169_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	169	0		29	10	S5884_169_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	169	0		29	10	S5884_169_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	169	0		29	10	S5884_169_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	169	0		29	10	S5884_169_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											88.00	50		50				86.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	169	0		29	10	S5884_169_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	169	0		29	10	S5884_169_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	169	0		29	10	S5884_169_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	170	0		29	10	S5884_170_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	170	0		29	10	S5884_170_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	170	0		29	10	S5884_170_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	170	0		29	10	S5884_170_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	170	0		29	10	S5884_170_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	170	0		29	10	S5884_170_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											78.00	50		50				76.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	170	0		29	10	S5884_170_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	170	0		29	10	S5884_170_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	170	0		29	10	S5884_170_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	171	0		29	10	S5884_171_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	171	0		29	10	S5884_171_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	171	0		29	10	S5884_171_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	171	0		29	10	S5884_171_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	171	0		29	10	S5884_171_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	171	0		29	10	S5884_171_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											78.00	50		50				77.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	171	0		29	10	S5884_171_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	171	0		29	10	S5884_171_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	171	0		29	10	S5884_171_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	172	0		29	10	S5884_172_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	172	0		29	10	S5884_172_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	172	0		29	10	S5884_172_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	172	0		29	10	S5884_172_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	172	0		29	10	S5884_172_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	172	0		29	10	S5884_172_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											98.00	39		39				98.00	39		39										39		39				39		39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	172	0		29	10	S5884_172_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	172	0		29	10	S5884_172_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	172	0		29	10	S5884_172_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	173	0		29	10	S5884_173_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	173	0		29	10	S5884_173_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	173	0		29	10	S5884_173_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	173	0		29	10	S5884_173_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	173	0		29	10	S5884_173_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	173	0		29	10	S5884_173_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											89.00	50		50				87.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	173	0		29	10	S5884_173_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	173	0		29	10	S5884_173_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	173	0		29	10	S5884_173_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	174	0		29	10	S5884_174_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	174	0		29	10	S5884_174_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	174	0		29	10	S5884_174_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	174	0		29	10	S5884_174_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	174	0		29	10	S5884_174_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	174	0		29	10	S5884_174_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											80.00	50		50				79.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	174	0		29	10	S5884_174_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	174	0		29	10	S5884_174_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	174	0		29	10	S5884_174_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	175	0		29	10	S5884_175_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	175	0		29	10	S5884_175_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	175	0		29	10	S5884_175_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	175	0		29	10	S5884_175_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	175	0		29	10	S5884_175_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	175	0		29	10	S5884_175_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											88.00	46		46				86.00	45		45										46		46				45		45			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	175	0		29	10	S5884_175_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	175	0		29	10	S5884_175_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	175	0		29	10	S5884_175_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	176	0		29	10	S5884_176_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	176	0		29	10	S5884_176_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	176	0		29	10	S5884_176_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	176	0		29	10	S5884_176_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	176	0		29	10	S5884_176_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	176	0		29	10	S5884_176_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											77.00	50		50				75.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	176	0		29	10	S5884_176_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	176	0		29	10	S5884_176_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	176	0		29	10	S5884_176_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	177	0		29	10	S5884_177_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	177	0		29	10	S5884_177_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	177	0		29	10	S5884_177_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	177	0		29	10	S5884_177_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	177	0		29	10	S5884_177_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	177	0		29	10	S5884_177_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											98.00	32		32				98.00	32		32										32		32				32		32			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	177	0		29	10	S5884_177_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												27							27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	177	0		29	10	S5884_177_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	177	0		29	10	S5884_177_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	178	0		29	10	S5884_178_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	178	0		29	10	S5884_178_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	178	0		29	10	S5884_178_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	178	0		29	10	S5884_178_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	178	0		29	10	S5884_178_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	178	0		29	10	S5884_178_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											67.00	50		50				65.00	49		49										50		50				49		49			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	178	0		29	10	S5884_178_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	178	0		29	10	S5884_178_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	178	0		29	10	S5884_178_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	179	0		29	10	S5884_179_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	179	0		29	10	S5884_179_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	179	0		29	10	S5884_179_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	179	0		29	10	S5884_179_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	179	0		29	10	S5884_179_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	179	0		29	10	S5884_179_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											91.00	41		41				89.00	40		40										41		41				40		40			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	179	0		29	10	S5884_179_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	179	0		29	10	S5884_179_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	179	0		29	10	S5884_179_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	180	0		29	10	S5884_180_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													5.00		15.00	1.00		3.00	5.00		15.00	1.00		0.00	5.00		5.00
S5884	180	0		29	10	S5884_180_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								5.00		15.00					1.00		3.00											5.00		15.00				1.00		0.00				5.00				5.00			0.17	0.03		0.17	0.03	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	180	0		29	10	S5884_180_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													10.00		30.00	4.00		12.00	10.00		30.00	4.00		0.00	10.00		10.00
S5884	180	0		29	10	S5884_180_0	1			Generic	4	11	3	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								10.00		30.00					4.00		12.00											10.00		30.00				4.00		0.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1		3															
S5884	180	0		29	10	S5884_180_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		90	2	2				30		90	30		31								47.00		141.00					45.00		135.00											47.00		141.00				45.00		125.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													25.00		75.00	20.00		60.00	25.00		75.00	20.00		50.00	25.00		25.00
S5884	180	0		29	10	S5884_180_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											95.00	45		45				95.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	180	0		29	10	S5884_180_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													35.00			35.00			35.00			35.00			35.00		35.00
S5884	180	0		29	10	S5884_180_0	1			Select Care Drugs	4	11	1	2	6	1		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs													11.00		33.00	0.00		0.00	11.00		33.00	0.00		0.00	11.00		11.00
S5884	180	0		29	10	S5884_180_0	1			Select Care Drugs	4	11	1	2	6	3		110	01		110	1				30		90	1	2				30		90	30		31								11.00		33.00					0.00		0.00											11.00		33.00				0.00		0.00				11.00				11.00			0.37	0.00		0.37	0.00	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs										1																	
S5884	181	0		29	10	S5884_181_0	9			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	181	0		29	10	S5884_181_0	9			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	181	0		29	10	S5884_181_0	9			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	181	0		29	10	S5884_181_0	9			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	181	0		29	10	S5884_181_0	9			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											61.00	25		25				42.00	17		17										25		25				17		17			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	181	0		29	10	S5884_181_0	9			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											93.00	50		50				93.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	181	0		29	10	S5884_181_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	182	0		29	10	S5884_182_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	182	0		29	10	S5884_182_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	182	0		29	10	S5884_182_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	182	0		29	10	S5884_182_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	182	0		29	10	S5884_182_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											46.00	19		19				39.00	16		16										19		19				16		16			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	182	0		29	10	S5884_182_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	47		47				99.00	47		47										47		47				47		47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	182	0		29	10	S5884_182_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	183	0		29	10	S5884_183_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	183	0		29	10	S5884_183_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	183	0		29	10	S5884_183_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	183	0		29	10	S5884_183_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	183	0		29	10	S5884_183_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											54.00	22		22				36.00	15		15										22		22				15		15			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	183	0		29	10	S5884_183_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	45		45				100.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	183	0		29	10	S5884_183_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	184	0		29	10	S5884_184_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	184	0		29	10	S5884_184_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	184	0		29	10	S5884_184_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	184	0		29	10	S5884_184_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	184	0		29	10	S5884_184_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											61.00	25		25				37.00	15		15										25		25				15		15			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	184	0		29	10	S5884_184_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	45		45				99.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	184	0		29	10	S5884_184_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	185	0		29	10	S5884_185_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	185	0		29	10	S5884_185_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	185	0		29	10	S5884_185_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	185	0		29	10	S5884_185_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	185	0		29	10	S5884_185_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											58.00	24		24				38.00	16		16										24		24				16		16			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	185	0		29	10	S5884_185_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											97.00	50		50				97.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	185	0		29	10	S5884_185_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	186	0		29	10	S5884_186_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	186	0		29	10	S5884_186_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	186	0		29	10	S5884_186_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	186	0		29	10	S5884_186_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	186	0		29	10	S5884_186_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											49.00	20		20				44.00	18		18										20		20				18		18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	186	0		29	10	S5884_186_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	47		47				100.00	47		47										47		47				47		47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	186	0		29	10	S5884_186_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	187	0		29	10	S5884_187_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	187	0		29	10	S5884_187_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	187	0		29	10	S5884_187_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	187	0		29	10	S5884_187_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	187	0		29	10	S5884_187_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											51.00	22		22				35.00	15		15										22		22				15		15			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	187	0		29	10	S5884_187_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	49		49				100.00	49		49										49		49				49		49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	187	0		29	10	S5884_187_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	188	0		29	10	S5884_188_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	188	0		29	10	S5884_188_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	188	0		29	10	S5884_188_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	188	0		29	10	S5884_188_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	188	0		29	10	S5884_188_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											45.00	20		20				38.00	17		17										20		20				17		17			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	188	0		29	10	S5884_188_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	47		47				97.00	46		46										47		47				46		46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	188	0		29	10	S5884_188_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	189	0		29	10	S5884_189_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	189	0		29	10	S5884_189_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	189	0		29	10	S5884_189_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	189	0		29	10	S5884_189_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	189	0		29	10	S5884_189_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											43.00	20		20				35.00	16		16										20		20				16		16			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	189	0		29	10	S5884_189_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	46		46				100.00	46		46										46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	189	0		29	10	S5884_189_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	190	0		29	10	S5884_190_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	190	0		29	10	S5884_190_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	190	0		29	10	S5884_190_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	190	0		29	10	S5884_190_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	190	0		29	10	S5884_190_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											53.00	24		24				37.00	17		17										24		24				17		17			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	190	0		29	10	S5884_190_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											96.00	50		50				96.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	190	0		29	10	S5884_190_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	191	0		29	10	S5884_191_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	191	0		29	10	S5884_191_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	191	0		29	10	S5884_191_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	191	0		29	10	S5884_191_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	191	0		29	10	S5884_191_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											50.00	22		22				36.00	16		16										22		22				16		16			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	191	0		29	10	S5884_191_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	45		45				99.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	191	0		29	10	S5884_191_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	192	0		29	10	S5884_192_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	192	0		29	10	S5884_192_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	192	0		29	10	S5884_192_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	192	0		29	10	S5884_192_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	192	0		29	10	S5884_192_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											65.00	25		25				42.00	16		16										25		25				16		16			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	192	0		29	10	S5884_192_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	46		46				100.00	46		46										46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	192	0		29	10	S5884_192_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	193	0		29	10	S5884_193_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	193	0		29	10	S5884_193_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	193	0		29	10	S5884_193_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	193	0		29	10	S5884_193_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	193	0		29	10	S5884_193_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											46.00	19		19				44.00	18		18										19		19				18		18			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	193	0		29	10	S5884_193_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	47		47				99.00	47		47										47		47				47		47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	193	0		29	10	S5884_193_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	194	0		29	10	S5884_194_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	194	0		29	10	S5884_194_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	194	0		29	10	S5884_194_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	194	0		29	10	S5884_194_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	194	0		29	10	S5884_194_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											48.00	20		20				43.00	18		18										20		20				18		18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	194	0		29	10	S5884_194_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	47		47				99.00	47		47										47		47				47		47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	194	0		29	10	S5884_194_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	195	0		29	10	S5884_195_0	2			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	195	0		29	10	S5884_195_0	2			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	195	0		29	10	S5884_195_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	195	0		29	10	S5884_195_0	2			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	195	0		29	10	S5884_195_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											69.00	25		25				50.00	18		18										25		25				18		18			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	195	0		29	10	S5884_195_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											91.00	46		46				91.00	46		46										46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	195	0		29	10	S5884_195_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	196	0		29	10	S5884_196_0	2			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	196	0		29	10	S5884_196_0	2			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	196	0		29	10	S5884_196_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	196	0		29	10	S5884_196_0	2			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	196	0		29	10	S5884_196_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											68.00	25		25				51.00	19		19										25		25				19		19			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	196	0		29	10	S5884_196_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											93.00	48		48				93.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	196	0		29	10	S5884_196_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	197	0		29	10	S5884_197_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	197	0		29	10	S5884_197_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	197	0		29	10	S5884_197_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	197	0		29	10	S5884_197_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	197	0		29	10	S5884_197_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											58.00	25		25				37.00	16		16										25		25				16		16			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	197	0		29	10	S5884_197_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											94.00	50		50				94.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	197	0		29	10	S5884_197_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	198	0		29	10	S5884_198_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	198	0		29	10	S5884_198_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	198	0		29	10	S5884_198_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	198	0		29	10	S5884_198_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	198	0		29	10	S5884_198_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											51.00	22		22				40.00	17		17										22		22				17		17			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	198	0		29	10	S5884_198_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	40		40				99.00	40		40										40		40				40		40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	198	0		29	10	S5884_198_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	199	0		29	10	S5884_199_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	199	0		29	10	S5884_199_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	199	0		29	10	S5884_199_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	199	0		29	10	S5884_199_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	199	0		29	10	S5884_199_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											55.00	22		22				40.00	16		16										22		22				16		16			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	199	0		29	10	S5884_199_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	49		49				99.00	49		49										49		49				49		49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	199	0		29	10	S5884_199_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	200	0		29	10	S5884_200_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	200	0		29	10	S5884_200_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	200	0		29	10	S5884_200_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	200	0		29	10	S5884_200_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	200	0		29	10	S5884_200_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											50.00	23		23				33.00	15		15										23		23				15		15			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	200	0		29	10	S5884_200_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	49		49				100.00	49		49										49		49				49		49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	200	0		29	10	S5884_200_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	201	0		29	10	S5884_201_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	201	0		29	10	S5884_201_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	201	0		29	10	S5884_201_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	201	0		29	10	S5884_201_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	201	0		29	10	S5884_201_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											57.00	24		24				38.00	16		16										24		24				16		16			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	201	0		29	10	S5884_201_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	46		46				99.00	46		46										46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	201	0		29	10	S5884_201_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	202	0		29	10	S5884_202_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	202	0		29	10	S5884_202_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	202	0		29	10	S5884_202_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	202	0		29	10	S5884_202_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	202	0		29	10	S5884_202_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											51.00	21		21				37.00	15		15										21		21				15		15			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	202	0		29	10	S5884_202_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	45		45				99.00	45		45										45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	202	0		29	10	S5884_202_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	203	0		29	10	S5884_203_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	203	0		29	10	S5884_203_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	203	0		29	10	S5884_203_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	203	0		29	10	S5884_203_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	203	0		29	10	S5884_203_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											52.00	21		21				42.00	17		17										21		21				17		17			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	203	0		29	10	S5884_203_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											93.00	50		50				93.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	203	0		29	10	S5884_203_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	204	0		29	10	S5884_204_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	204	0		29	10	S5884_204_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	204	0		29	10	S5884_204_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	204	0		29	10	S5884_204_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	204	0		29	10	S5884_204_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											67.00	25		25				43.00	16		16										25		25				16		16			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	204	0		29	10	S5884_204_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											94.00	50		50				94.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	204	0		29	10	S5884_204_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	205	0		29	10	S5884_205_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	205	0		29	10	S5884_205_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	205	0		29	10	S5884_205_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	205	0		29	10	S5884_205_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	205	0		29	10	S5884_205_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											51.00	21		21				41.00	17		17										21		21				17		17			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	205	0		29	10	S5884_205_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											94.00	50		50				94.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	205	0		29	10	S5884_205_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	206	0		29	10	S5884_206_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	206	0		29	10	S5884_206_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	206	0		29	10	S5884_206_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	206	0		29	10	S5884_206_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	206	0		29	10	S5884_206_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											59.00	24		24				39.00	16		16										24		24				16		16			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	206	0		29	10	S5884_206_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	50		50				100.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	206	0		29	10	S5884_206_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	207	0		29	10	S5884_207_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	207	0		29	10	S5884_207_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	207	0		29	10	S5884_207_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	207	0		29	10	S5884_207_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	207	0		29	10	S5884_207_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											55.00	22		22				45.00	18		18										22		22				18		18			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	207	0		29	10	S5884_207_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	47		47				100.00	47		47										47		47				47		47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	207	0		29	10	S5884_207_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	208	0		29	10	S5884_208_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	208	0		29	10	S5884_208_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	208	0		29	10	S5884_208_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	208	0		29	10	S5884_208_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	208	0		29	10	S5884_208_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											58.00	24		24				36.00	15		15										24		24				15		15			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	208	0		29	10	S5884_208_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	41		41				100.00	41		41										41		41				41		41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	208	0		29	10	S5884_208_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	209	0		29	10	S5884_209_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	209	0		29	10	S5884_209_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	209	0		29	10	S5884_209_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	209	0		29	10	S5884_209_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	209	0		29	10	S5884_209_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											59.00	24		24				44.00	18		18										24		24				18		18			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	209	0		29	10	S5884_209_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											92.00	50		50				92.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	209	0		29	10	S5884_209_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	210	0		29	10	S5884_210_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	210	0		29	10	S5884_210_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	210	0		29	10	S5884_210_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	210	0		29	10	S5884_210_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	210	0		29	10	S5884_210_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											55.00	22		22				38.00	15		15										22		22				15		15			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	210	0		29	10	S5884_210_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	48		48				99.00	48		48										48		48				48		48			48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	210	0		29	10	S5884_210_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	211	0		29	10	S5884_211_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	211	0		29	10	S5884_211_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	211	0		29	10	S5884_211_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	211	0		29	10	S5884_211_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	211	0		29	10	S5884_211_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											46.00	20		20				35.00	15		15										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	211	0		29	10	S5884_211_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											100.00	47		47				100.00	47		47										47		47				47		47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	211	0		29	10	S5884_211_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	212	0		29	10	S5884_212_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	212	0		29	10	S5884_212_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	212	0		29	10	S5884_212_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	212	0		29	10	S5884_212_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	212	0		29	10	S5884_212_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											59.00	23		23				41.00	16		16										23		23				16		16			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	212	0		29	10	S5884_212_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	50		50				99.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	212	0		29	10	S5884_212_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5884	213	0		29	10	S5884_213_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00
S5884	213	0		29	10	S5884_213_0	1			Preferred Generic	4	11	1	2	1	3		110	01		110	1				30		90	1	2				30		90	30		31								10.00		30.00					0.00		0.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	213	0		29	10	S5884_213_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00		60.00	1.00		3.00	20.00		60.00	1.00		3.00	20.00		20.00
S5884	213	0		29	10	S5884_213_0	1			Generic	4	11	1	2	2	3		110	01		110	1				30		90	2	2				30		90	30		31								20.00		60.00					1.00		3.00											20.00		60.00				1.00		3.00				20.00				20.00			0.67	0.03		0.67	0.03	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5884	213	0		29	10	S5884_213_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											58.00	22		22				42.00	16		16										22		22				16		16			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	213	0		29	10	S5884_213_0	1			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	2	2				30		90	30		31											99.00	43		43				99.00	43		43										43		43				43		43			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00
S5884	213	0		29	10	S5884_213_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S5904	001	0		29	10	S5904_001_0	7			Preferred Generic	3	01	1	2	1	1	110		01	110		1	31		90				1	2	31		90				31		31	6.00		18.00																			6.00		18.00																6.00				6.00		0.19			0.19			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5904	001	0		29	10	S5904_001_0	7			Generic	3	01	1	2	2	1	110		01	110		1	31		90				1	2	31		90				31		31	16.00		48.00																			16.00		48.00																16.00				16.00		0.52			0.52			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5904	001	0		29	10	S5904_001_0	7			Preferred Brand	3	10	1	2	3	1	110		01	110		1	31		90				1	2	31		90				31		31	47.00		141.00																			47.00		141.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5904	001	0		29	10	S5904_001_0	7			Non-Preferred Drug	3	10	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				88.66	50		50																		50		50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5904	001	0		29	10	S5904_001_0	7			Specialty Tier	3	10	1	1	5	1	010		01	010		1	31								31						31		31				1476.40	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
S5904	002	0		29	10	S5904_002_0	7			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		90				1	1	31		90				31		31	3.00		9.00																			3.00		9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5904	002	0		29	10	S5904_002_0	7			Preferred Generic	4	01	1	2	1	3	110		01	110		1	31		90				1	1	31		90				31		31	3.00		9.00																			3.00		9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5904	002	0		29	10	S5904_002_0	7			Generic	4	01	1	2	2	1	110		01	110		1	31		90				1	1	31		90				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5904	002	0		29	10	S5904_002_0	7			Generic	4	01	1	2	2	3	110		01	110		1	31		90				1	1	31		90				31		31	10.00		30.00																			10.00		30.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5904	002	0		29	10	S5904_002_0	7			Preferred Brand	4	11	1	2	3	1	110		01	110		1	31		90				1	1	31		90				31		31	40.00		120.00																			40.00		120.00																40.00				40.00		1.29			1.29			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5904	002	0		29	10	S5904_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	31		90				1	1	31		90				31		31	93.00		279.00																			93.00		279.00																93.00				93.00		3.00			3.00			3.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00				35.00		105.00				35.00		35.00
S5904	002	0		29	10	S5904_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1501.66	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00						35.00						35.00		35.00
S5916	001	0		29	10	S5916_001_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					3.00	6.00	9.00					3.00	6.00	9.00																10.00				10.00			0.33	0.10	0.10			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00	3.00	6.00	9.00	3.00	6.00	9.00				10.00		10.00
S5916	001	0		29	10	S5916_001_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								17.00	34.00	51.00					13.00	26.00	39.00					13.00	26.00	39.00																17.00				17.00			0.57	0.43	0.43			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													17.00	34.00	51.00	13.00	26.00	39.00	13.00	26.00	39.00				17.00		17.00
S5916	001	0		29	10	S5916_001_0	4			Preferred Brand	3	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																47.00				47.00			1.57	1.33	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5916	001	0		29	10	S5916_001_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											60.46	45	45	45				53.75	40	40	40				40	40	40															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5916	001	0		29	10	S5916_001_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											926.97	25						926.97	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5916	002	0		29	10	S5916_002_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	6.00				3.00	6.00	6.00				3.00		3.00
S5916	002	0		29	10	S5916_002_0	7			Preferred Generic	4	01	1	2	1	3	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	6.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5916	002	0		29	10	S5916_002_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	20.00				10.00	20.00	20.00				10.00		10.00
S5916	002	0		29	10	S5916_002_0	7			Preferred Brand	4	10	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	117.50																			47.00	94.00	117.50																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S5916	002	0		29	10	S5916_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				53.75	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S5916	002	0		29	10	S5916_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1223.59	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	348	0		29	10	S5921_348_0	3			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	348	0		29	10	S5921_348_0	3			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	348	0		29	10	S5921_348_0	3			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											20.00	15		15				24.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	348	0		29	10	S5921_348_0	3			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											46.00	42		42				49.00	39		39												42						39			42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	348	0		29	10	S5921_348_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											285.00	25						239.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	349	0		29	10	S5921_349_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	349	0		29	10	S5921_349_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	349	0		29	10	S5921_349_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	16		16				28.00	16		16												16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	349	0		29	10	S5921_349_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											48.00	45		45				46.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	349	0		29	10	S5921_349_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											241.00	25						263.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	350	0		29	10	S5921_350_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	350	0		29	10	S5921_350_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	350	0		29	10	S5921_350_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	350	0		29	10	S5921_350_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											52.00	47		47				46.00	44		44												47						44			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	350	0		29	10	S5921_350_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											346.00	25						288.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	351	0		29	10	S5921_351_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	351	0		29	10	S5921_351_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	351	0		29	10	S5921_351_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											21.00	15		15				26.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	351	0		29	10	S5921_351_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											44.00	45		45				45.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	351	0		29	10	S5921_351_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											265.00	25						270.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	352	0		29	10	S5921_352_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	352	0		29	10	S5921_352_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	352	0		29	10	S5921_352_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											22.00	16		16				28.00	16		16												16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	352	0		29	10	S5921_352_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											45.00	43		43				44.00	40		40												43						40			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	352	0		29	10	S5921_352_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											300.00	25						307.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	353	0		29	10	S5921_353_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	353	0		29	10	S5921_353_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					18.00		54.00													60.00						54.00				20.00				20.00			0.66	0.60				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	353	0		29	10	S5921_353_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	353	0		29	10	S5921_353_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											47.00	47		47				45.00	44		44												47						44			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	353	0		29	10	S5921_353_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											252.00	25						393.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	354	0		29	10	S5921_354_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								19.00		57.00					13.00		39.00													57.00						39.00				19.00				19.00			0.63	0.43				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	354	0		29	10	S5921_354_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					18.00		54.00													60.00						54.00				20.00				20.00			0.66	0.60				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	354	0		29	10	S5921_354_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	354	0		29	10	S5921_354_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											51.00	50		50				46.00	47		47												50						47			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	354	0		29	10	S5921_354_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											395.00	25						74.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	355	0		29	10	S5921_355_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								19.00		57.00					13.00		39.00													57.00						39.00				19.00				19.00			0.63	0.43				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	355	0		29	10	S5921_355_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					18.00		54.00													60.00						54.00				20.00				20.00			0.66	0.60				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	355	0		29	10	S5921_355_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	355	0		29	10	S5921_355_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											52.00	50		50				45.00	47		47												50						47			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	355	0		29	10	S5921_355_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											287.00	25						241.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	356	0		29	10	S5921_356_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	356	0		29	10	S5921_356_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					18.00		54.00													60.00						54.00				20.00				20.00			0.66	0.60				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	356	0		29	10	S5921_356_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	356	0		29	10	S5921_356_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											49.00	50		50				51.00	47		47												50						47			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	356	0		29	10	S5921_356_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											293.00	25						250.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	357	0		29	10	S5921_357_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	357	0		29	10	S5921_357_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	357	0		29	10	S5921_357_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											18.00	15		15				23.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	357	0		29	10	S5921_357_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											46.00	45		45				45.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	357	0		29	10	S5921_357_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											289.00	25						260.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	358	0		29	10	S5921_358_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	358	0		29	10	S5921_358_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	358	0		29	10	S5921_358_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											20.00	15		15				24.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	358	0		29	10	S5921_358_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											48.00	45		45				48.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	358	0		29	10	S5921_358_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											307.00	25						194.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	359	0		29	10	S5921_359_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					11.00		33.00													51.00						33.00				17.00				17.00			0.56	0.36				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	359	0		29	10	S5921_359_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					18.00		54.00													60.00						54.00				20.00				20.00			0.66	0.60				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	359	0		29	10	S5921_359_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	359	0		29	10	S5921_359_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											49.00	50		50				44.00	47		47												50						47			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	359	0		29	10	S5921_359_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											202.00	25						209.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	360	0		29	10	S5921_360_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	360	0		29	10	S5921_360_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	360	0		29	10	S5921_360_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											23.00	17		17				29.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	360	0		29	10	S5921_360_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											44.00	45		45				39.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	360	0		29	10	S5921_360_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											280.00	25						259.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	361	0		29	10	S5921_361_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	361	0		29	10	S5921_361_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	361	0		29	10	S5921_361_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											19.00	15		15				22.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	361	0		29	10	S5921_361_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											45.00	44		44				45.00	41		41												44						41			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	361	0		29	10	S5921_361_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											208.00	25						261.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	362	0		29	10	S5921_362_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	362	0		29	10	S5921_362_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	362	0		29	10	S5921_362_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				30.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	362	0		29	10	S5921_362_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											46.00	47		47				43.00	44		44												47						44			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	362	0		29	10	S5921_362_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											214.00	25						238.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	363	0		29	10	S5921_363_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	363	0		29	10	S5921_363_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	363	0		29	10	S5921_363_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								44.00		132.00					44.00		132.00													132.00						132.00				44.00				44.00			1.46	1.46				1.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	363	0		29	10	S5921_363_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											42.00	45		45				36.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	363	0		29	10	S5921_363_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											290.00	25						172.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	364	0		29	10	S5921_364_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	364	0		29	10	S5921_364_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	364	0		29	10	S5921_364_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								46.00		138.00					46.00		138.00													138.00						138.00				46.00				46.00			1.53	1.53				1.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	364	0		29	10	S5921_364_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											43.00	45		45				34.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	364	0		29	10	S5921_364_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											272.00	25						265.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	365	0		29	10	S5921_365_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	365	0		29	10	S5921_365_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	365	0		29	10	S5921_365_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								44.00		132.00					44.00		132.00													132.00						132.00				44.00				44.00			1.46	1.46				1.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	365	0		29	10	S5921_365_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											43.00	45		45				41.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	365	0		29	10	S5921_365_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											111.00	25						232.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	366	0		29	10	S5921_366_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	366	0		29	10	S5921_366_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	366	0		29	10	S5921_366_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											22.00	15		15				26.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	366	0		29	10	S5921_366_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											52.00	45		45				51.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	366	0		29	10	S5921_366_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											285.00	25						332.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	367	0		29	10	S5921_367_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	367	0		29	10	S5921_367_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	367	0		29	10	S5921_367_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	367	0		29	10	S5921_367_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											51.00	47		47				46.00	44		44												47						44			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	367	0		29	10	S5921_367_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											208.00	25						366.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	368	0		29	10	S5921_368_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	368	0		29	10	S5921_368_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	368	0		29	10	S5921_368_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	368	0		29	10	S5921_368_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											41.00	45		45				36.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	368	0		29	10	S5921_368_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											242.00	25						318.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	369	0		29	10	S5921_369_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	369	0		29	10	S5921_369_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	369	0		29	10	S5921_369_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								44.00		132.00					44.00		132.00													132.00						132.00				44.00				44.00			1.46	1.46				1.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	369	0		29	10	S5921_369_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											45.00	45		45				35.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	369	0		29	10	S5921_369_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											289.00	25						279.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	370	0		29	10	S5921_370_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	370	0		29	10	S5921_370_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	370	0		29	10	S5921_370_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											19.00	15		15				23.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	370	0		29	10	S5921_370_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											45.00	43		43				44.00	40		40												43						40			43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	370	0		29	10	S5921_370_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											259.00	25						254.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	371	0		29	10	S5921_371_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	371	0		29	10	S5921_371_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	371	0		29	10	S5921_371_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											20.00	15		15				23.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	371	0		29	10	S5921_371_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											50.00	45		45				55.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	371	0		29	10	S5921_371_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											303.00	25						180.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	372	0		29	10	S5921_372_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								19.00		57.00					13.00		39.00													57.00						39.00				19.00				19.00			0.63	0.43				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	372	0		29	10	S5921_372_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					18.00		54.00													60.00						54.00				20.00				20.00			0.66	0.60				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	372	0		29	10	S5921_372_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	372	0		29	10	S5921_372_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											60.00	50		50				53.00	47		47												50						47			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	372	0		29	10	S5921_372_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											266.00	25						225.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	373	0		29	10	S5921_373_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	373	0		29	10	S5921_373_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	373	0		29	10	S5921_373_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	373	0		29	10	S5921_373_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											51.00	49		49				55.00	46		46												49						46			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	373	0		29	10	S5921_373_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											177.00	25						286.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	374	0		29	10	S5921_374_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	374	0		29	10	S5921_374_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	374	0		29	10	S5921_374_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											21.00	16		16				25.00	16		16												16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	374	0		29	10	S5921_374_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											47.00	44		44				47.00	41		41												44						41			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	374	0		29	10	S5921_374_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											331.00	25						217.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	375	0		29	10	S5921_375_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	375	0		29	10	S5921_375_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	375	0		29	10	S5921_375_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											19.00	15		15				22.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	375	0		29	10	S5921_375_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											48.00	45		45				45.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	375	0		29	10	S5921_375_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											264.00	25						276.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	376	0		29	10	S5921_376_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	376	0		29	10	S5921_376_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	376	0		29	10	S5921_376_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	376	0		29	10	S5921_376_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											48.00	40		40				40.00	37		37												40						37			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	376	0		29	10	S5921_376_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											281.00	25						305.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	377	0		29	10	S5921_377_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	377	0		29	10	S5921_377_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								16.00		48.00					14.00		42.00													48.00						42.00				16.00				16.00			0.53	0.46				0.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	377	0		29	10	S5921_377_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	377	0		29	10	S5921_377_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											57.00	50		50				56.00	47		47												50						47			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	377	0		29	10	S5921_377_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											451.00	25						456.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	378	0		29	10	S5921_378_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	378	0		29	10	S5921_378_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	378	0		29	10	S5921_378_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	378	0		29	10	S5921_378_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											44.00	46		46				42.00	43		43												46						43			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	378	0		29	10	S5921_378_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											191.00	25						329.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	379	0		29	10	S5921_379_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	379	0		29	10	S5921_379_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	379	0		29	10	S5921_379_0	2			Preferred Brand	2	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								47.00		141.00					47.00		141.00													141.00						141.00				47.00				47.00			1.56	1.56				1.51	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	379	0		29	10	S5921_379_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											54.00	45		45				46.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	379	0		29	10	S5921_379_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											208.00	25						249.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	380	0		29	10	S5921_380_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	380	0		29	10	S5921_380_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	380	0		29	10	S5921_380_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				28.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	380	0		29	10	S5921_380_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											51.00	45		45				51.00	42		42												45						42			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	380	0		29	10	S5921_380_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											362.00	25						200.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	381	0		29	10	S5921_381_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.26	0.06				0.25	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	381	0		29	10	S5921_381_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					8.00		24.00													30.00						24.00				10.00				10.00			0.33	0.26				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	381	0		29	10	S5921_381_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											21.00	14		14				25.00	14		14												14						14			14			14								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	381	0		29	10	S5921_381_0	2			Non-Preferred Drug	2	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											63.00	44		44				64.00	41		41												44						41			44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	381	0		29	10	S5921_381_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											403.00	25						418.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	382	0		29	10	S5921_382_0	3			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	382	0		29	10	S5921_382_0	3			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	382	0		29	10	S5921_382_0	3			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	382	0		29	10	S5921_382_0	3			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	382	0		29	10	S5921_382_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	382	0		29	10	S5921_382_0	3			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											81.00	50		50				65.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	382	0		29	10	S5921_382_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											262.00	27						388.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	383	0		29	10	S5921_383_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	383	0		29	10	S5921_383_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	383	0		29	10	S5921_383_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	383	0		29	10	S5921_383_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	383	0		29	10	S5921_383_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	383	0		29	10	S5921_383_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											70.00	50		50				62.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	383	0		29	10	S5921_383_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											290.00	27						352.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	384	0		29	10	S5921_384_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	384	0		29	10	S5921_384_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	384	0		29	10	S5921_384_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	384	0		29	10	S5921_384_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	384	0		29	10	S5921_384_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	384	0		29	10	S5921_384_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											59.00	50		50				68.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	384	0		29	10	S5921_384_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											282.00	27						697.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	385	0		29	10	S5921_385_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	385	0		29	10	S5921_385_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	385	0		29	10	S5921_385_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	385	0		29	10	S5921_385_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	385	0		29	10	S5921_385_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	385	0		29	10	S5921_385_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											75.00	50		50				64.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	385	0		29	10	S5921_385_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											297.00	27						295.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	386	0		29	10	S5921_386_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	386	0		29	10	S5921_386_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	386	0		29	10	S5921_386_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	386	0		29	10	S5921_386_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	386	0		29	10	S5921_386_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	386	0		29	10	S5921_386_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											69.00	50		50				63.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	386	0		29	10	S5921_386_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											192.00	27						348.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	387	0		29	10	S5921_387_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	387	0		29	10	S5921_387_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	387	0		29	10	S5921_387_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	387	0		29	10	S5921_387_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	387	0		29	10	S5921_387_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	387	0		29	10	S5921_387_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											71.00	50		50				59.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	387	0		29	10	S5921_387_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											253.00	27						204.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	388	0		29	10	S5921_388_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	388	0		29	10	S5921_388_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	388	0		29	10	S5921_388_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	388	0		29	10	S5921_388_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	388	0		29	10	S5921_388_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	388	0		29	10	S5921_388_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											58.00	50		50				59.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	388	0		29	10	S5921_388_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											188.00	27						476.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	389	0		29	10	S5921_389_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	389	0		29	10	S5921_389_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	389	0		29	10	S5921_389_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	389	0		29	10	S5921_389_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	389	0		29	10	S5921_389_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	389	0		29	10	S5921_389_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											67.00	50		50				66.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	389	0		29	10	S5921_389_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											360.00	27						186.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	390	0		29	10	S5921_390_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	390	0		29	10	S5921_390_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	390	0		29	10	S5921_390_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	390	0		29	10	S5921_390_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	390	0		29	10	S5921_390_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	390	0		29	10	S5921_390_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											62.00	50		50				63.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	390	0		29	10	S5921_390_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											320.00	27						211.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	391	0		29	10	S5921_391_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	391	0		29	10	S5921_391_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	391	0		29	10	S5921_391_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	391	0		29	10	S5921_391_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	391	0		29	10	S5921_391_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	391	0		29	10	S5921_391_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											69.00	50		50				64.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	391	0		29	10	S5921_391_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											307.00	27						321.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	392	0		29	10	S5921_392_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	392	0		29	10	S5921_392_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	392	0		29	10	S5921_392_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	392	0		29	10	S5921_392_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	392	0		29	10	S5921_392_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	392	0		29	10	S5921_392_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											63.00	50		50				54.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	392	0		29	10	S5921_392_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											234.00	27						412.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	393	0		29	10	S5921_393_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	393	0		29	10	S5921_393_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	393	0		29	10	S5921_393_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	393	0		29	10	S5921_393_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	393	0		29	10	S5921_393_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	393	0		29	10	S5921_393_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											65.00	50		50				59.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	393	0		29	10	S5921_393_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											147.00	27						455.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	394	0		29	10	S5921_394_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	394	0		29	10	S5921_394_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	394	0		29	10	S5921_394_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	394	0		29	10	S5921_394_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	394	0		29	10	S5921_394_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	394	0		29	10	S5921_394_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											66.00	50		50				57.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	394	0		29	10	S5921_394_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											354.00	27						560.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	395	0		29	10	S5921_395_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	395	0		29	10	S5921_395_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	395	0		29	10	S5921_395_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	395	0		29	10	S5921_395_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	395	0		29	10	S5921_395_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	395	0		29	10	S5921_395_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											59.00	50		50				56.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	395	0		29	10	S5921_395_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											250.00	27						106.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	396	0		29	10	S5921_396_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	396	0		29	10	S5921_396_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	396	0		29	10	S5921_396_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	396	0		29	10	S5921_396_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	396	0		29	10	S5921_396_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	396	0		29	10	S5921_396_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											65.00	50		50				55.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	396	0		29	10	S5921_396_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											181.00	27						99.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	397	0		29	10	S5921_397_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	397	0		29	10	S5921_397_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	397	0		29	10	S5921_397_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	397	0		29	10	S5921_397_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	397	0		29	10	S5921_397_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	397	0		29	10	S5921_397_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											57.00	50		50				52.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	397	0		29	10	S5921_397_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											149.00	27						123.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	398	0		29	10	S5921_398_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	398	0		29	10	S5921_398_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	398	0		29	10	S5921_398_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	398	0		29	10	S5921_398_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	398	0		29	10	S5921_398_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	398	0		29	10	S5921_398_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											56.00	50		50				56.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	398	0		29	10	S5921_398_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											147.00	27						346.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	399	0		29	10	S5921_399_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	399	0		29	10	S5921_399_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	399	0		29	10	S5921_399_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	399	0		29	10	S5921_399_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	399	0		29	10	S5921_399_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	399	0		29	10	S5921_399_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											58.00	50		50				63.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	399	0		29	10	S5921_399_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											210.00	27						175.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	400	0		29	10	S5921_400_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	400	0		29	10	S5921_400_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	400	0		29	10	S5921_400_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	400	0		29	10	S5921_400_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	400	0		29	10	S5921_400_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	400	0		29	10	S5921_400_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											61.00	50		50				52.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	400	0		29	10	S5921_400_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											393.00	27						78.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	401	0		29	10	S5921_401_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	401	0		29	10	S5921_401_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	401	0		29	10	S5921_401_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	401	0		29	10	S5921_401_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	401	0		29	10	S5921_401_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	401	0		29	10	S5921_401_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											51.00	50		50				53.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	401	0		29	10	S5921_401_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											293.00	27						0.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	402	0		29	10	S5921_402_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	402	0		29	10	S5921_402_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	402	0		29	10	S5921_402_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	402	0		29	10	S5921_402_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	402	0		29	10	S5921_402_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	402	0		29	10	S5921_402_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											60.00	50		50				64.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	402	0		29	10	S5921_402_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											335.00	27						700.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	403	0		29	10	S5921_403_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	403	0		29	10	S5921_403_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	403	0		29	10	S5921_403_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	403	0		29	10	S5921_403_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	403	0		29	10	S5921_403_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	403	0		29	10	S5921_403_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											69.00	50		50				62.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	403	0		29	10	S5921_403_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											237.00	27						275.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	404	0		29	10	S5921_404_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	404	0		29	10	S5921_404_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	404	0		29	10	S5921_404_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	404	0		29	10	S5921_404_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	404	0		29	10	S5921_404_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	404	0		29	10	S5921_404_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											76.00	50		50				64.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	404	0		29	10	S5921_404_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											187.00	27						109.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	405	0		29	10	S5921_405_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	405	0		29	10	S5921_405_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	405	0		29	10	S5921_405_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	405	0		29	10	S5921_405_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	405	0		29	10	S5921_405_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	405	0		29	10	S5921_405_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											57.00	50		50				55.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	405	0		29	10	S5921_405_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											157.00	27						381.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	406	0		29	10	S5921_406_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	406	0		29	10	S5921_406_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	406	0		29	10	S5921_406_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	406	0		29	10	S5921_406_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	406	0		29	10	S5921_406_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	406	0		29	10	S5921_406_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											60.00	50		50				56.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	406	0		29	10	S5921_406_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											188.00	27						191.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	407	0		29	10	S5921_407_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	407	0		29	10	S5921_407_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	407	0		29	10	S5921_407_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	407	0		29	10	S5921_407_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	407	0		29	10	S5921_407_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	407	0		29	10	S5921_407_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											75.00	50		50				68.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	407	0		29	10	S5921_407_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											90.00	27						458.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	408	0		29	10	S5921_408_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	408	0		29	10	S5921_408_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	408	0		29	10	S5921_408_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	408	0		29	10	S5921_408_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	408	0		29	10	S5921_408_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	408	0		29	10	S5921_408_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											63.00	50		50				61.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	408	0		29	10	S5921_408_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											313.00	27						332.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	409	0		29	10	S5921_409_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	409	0		29	10	S5921_409_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	409	0		29	10	S5921_409_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	409	0		29	10	S5921_409_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	409	0		29	10	S5921_409_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	409	0		29	10	S5921_409_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											66.00	50		50				66.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	409	0		29	10	S5921_409_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											193.00	27						231.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	410	0		29	10	S5921_410_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	410	0		29	10	S5921_410_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	410	0		29	10	S5921_410_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	410	0		29	10	S5921_410_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	410	0		29	10	S5921_410_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	410	0		29	10	S5921_410_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											70.00	50		50				70.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	410	0		29	10	S5921_410_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											332.00	27						531.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	411	0		29	10	S5921_411_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	411	0		29	10	S5921_411_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	411	0		29	10	S5921_411_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	411	0		29	10	S5921_411_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	411	0		29	10	S5921_411_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	411	0		29	10	S5921_411_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											61.00	50		50				65.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	411	0		29	10	S5921_411_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											119.00	27						185.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	412	0		29	10	S5921_412_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	412	0		29	10	S5921_412_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	412	0		29	10	S5921_412_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	412	0		29	10	S5921_412_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	412	0		29	10	S5921_412_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	412	0		29	10	S5921_412_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											67.00	50		50				56.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	412	0		29	10	S5921_412_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											326.00	27						53.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	413	0		29	10	S5921_413_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	413	0		29	10	S5921_413_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	413	0		29	10	S5921_413_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	413	0		29	10	S5921_413_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	413	0		29	10	S5921_413_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	413	0		29	10	S5921_413_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											74.00	50		50				70.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	413	0		29	10	S5921_413_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											299.00	27						404.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	414	0		29	10	S5921_414_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	414	0		29	10	S5921_414_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	414	0		29	10	S5921_414_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	414	0		29	10	S5921_414_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	414	0		29	10	S5921_414_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	414	0		29	10	S5921_414_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											76.00	50		50				88.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	414	0		29	10	S5921_414_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											507.00	27						204.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	415	0		29	10	S5921_415_0	2			Preferred Generic	4	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	415	0		29	10	S5921_415_0	2			Preferred Generic	4	01	1	2	1	3		110	01		100	1				30		90	2	2						90	30		31								17.00		51.00					2.00		6.00													51.00						6.00				17.00				17.00			0.56	0.06				0.54	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5921	415	0		29	10	S5921_415_0	2			Generic	4	01	3	2	2	1		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5921	415	0		29	10	S5921_415_0	2			Generic	4	01	3	2	2	3		110	01		100	1				30		90	2	2						90	30		31								20.00		60.00					8.00		24.00													60.00						24.00				20.00				20.00			0.66	0.26				0.64	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										2		2															
S5921	415	0		29	10	S5921_415_0	2			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	2	2						90	30		31								45.00		135.00					40.00		120.00													135.00						120.00				45.00				45.00			1.50	1.33				1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	415	0		29	10	S5921_415_0	2			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				30		90	2	2						90	30		31											99.00	50		50				64.00	50		50												50						50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S5921	415	0		29	10	S5921_415_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											146.00	27						555.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	001	0		29	10	S5953_001_0	4			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								12.00	24.00	36.00					8.00	16.00	24.00					8.00	16.00	20.00																12.00				8.00			0.40	0.27	0.27			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	001	0		29	10	S5953_001_0	4			Generic	3	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					18.00	36.00	54.00					18.00	36.00	45.00																20.00				18.00			0.67	0.60	0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	001	0		29	10	S5953_001_0	4			Preferred Brand	3	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	105.00																47.00				42.00			1.57	1.40	1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00
S5953	001	0		29	10	S5953_001_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											95.41	46	46	46				90.69	45	45	45				45	45	45															46			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	001	0		29	10	S5953_001_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	002	0		29	10	S5953_002_0	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	002	0		29	10	S5953_002_0	3			Preferred Generic	4	01	1	2	1	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5953	002	0		29	10	S5953_002_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								8.00	16.00	24.00					3.00	6.00	9.00					3.00	6.00	7.50																8.00				3.00			0.27	0.10	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	002	0		29	10	S5953_002_0	3			Generic	4	01	1	2	2	3		111	01	111		1				30	60	90	2	2	30	60	90				30		31								8.00	16.00	24.00					3.00	6.00	9.00					3.00	6.00	7.50																8.00				3.00			0.27	0.10	0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5953	002	0		29	10	S5953_002_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								27.00	54.00	81.00					20.00	40.00	60.00					20.00	40.00	50.00																27.00				20.00			0.90	0.67	0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													27.00	54.00	81.00	20.00	40.00	60.00	20.00	40.00	50.00				27.00		20.00
S5953	002	0		29	10	S5953_002_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											61.73	45	45	45				56.15	40	40	40				40	40	40															45			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	002	0		29	10	S5953_002_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	004	0		29	10	S5953_004_0	3			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								10.00	20.00	30.00					5.00	10.00	15.00					5.00	10.00	12.50																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	004	0		29	10	S5953_004_0	3			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								19.00	38.00	57.00					14.00	28.00	42.00					14.00	28.00	22.50																19.00				14.00			0.63	0.47	0.47			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	004	0		29	10	S5953_004_0	3			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	100.00																45.00				40.00			1.50	1.33	1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	100.00				35.00		35.00
S5953	004	0		29	10	S5953_004_0	3			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											95.41	50	50	50				90.69	45	45	45				45	45	45															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5953	004	0		29	10	S5953_004_0	3			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S5993	001	0		29	10	S5993_001_0	8			Preferred Generic	2	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00		0.33				0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													10.00	20.00	30.00				10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00
S5993	001	0		29	10	S5993_001_0	8			Generic	2	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	20.00	40.00	60.00																									20.00	40.00	60.00				10.00	20.00	30.00				20.00				20.00		0.67				0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													20.00	40.00	60.00				20.00	40.00	60.00	10.00	20.00	30.00	20.00		20.00
S5993	001	0		29	10	S5993_001_0	8			Preferred Brand	2	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	40.00	80.00	120.00																									40.00	80.00	120.00				40.00	80.00	120.00				40.00				40.00		1.33				1.33	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5993	001	0		29	10	S5993_001_0	8			Non-Preferred Drug	2	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				37.96	45	45	45																								45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5993	001	0		29	10	S5993_001_0	8			Specialty Tier	2	11	1	1	5	1	010		01		000	1	30														30		31				185.24	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
S5993	003	0		29	10	S5993_003_0	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00
S5993	003	0		29	10	S5993_003_0	7			Preferred Generic	4	01	1	2	1	3	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5993	003	0		29	10	S5993_003_0	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	1				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													8.00	16.00	24.00				8.00	16.00	24.00	4.00	8.00	12.00	8.00		8.00
S5993	003	0		29	10	S5993_003_0	7			Generic	4	01	1	2	2	3	111		01		111	1	30	60	90				1	1				30	60	90	30		31	8.00	16.00	24.00																									8.00	16.00	24.00				4.00	8.00	12.00				8.00				8.00		0.27				0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier										1																	
S5993	003	0		29	10	S5993_003_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	40.00	80.00	120.00																									40.00	80.00	120.00				40.00	80.00	120.00				40.00				40.00		1.33				1.33	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5993	003	0		29	10	S5993_003_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				62.41	45	45	45																								45	45	45				45	45	45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S5993	003	0		29	10	S5993_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				475.84	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00												35.00		35.00
S6506	001	0		29	10	S6506_001_0	2			Preferred Generic	2	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
S6506	001	0		29	10	S6506_001_0	2			Generic	2	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	9.00																			3.00	6.00	9.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	9.00				3.00	6.00	9.00				3.00		3.00
S6506	001	0		29	10	S6506_001_0	2			Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				58.20	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S6506	001	0		29	10	S6506_001_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				69.13	33	33	33																		33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S6506	001	0		29	10	S6506_001_0	2			Specialty Tier	2	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					25	25																																				25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00											35.00		35.00
S6506	002	0		29	10	S6506_002_0	2			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00
S6506	002	0		29	10	S6506_002_0	2			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	7.50																			3.00	6.00	7.50																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													3.00	6.00	7.50				3.00	6.00	7.50				3.00		3.00
S6506	002	0		29	10	S6506_002_0	2			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				30.00	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S6506	002	0		29	10	S6506_002_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				54.86	45	45	45																		45	45	45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00
S6506	002	0		29	10	S6506_002_0	2			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31					33	33																																				33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00											35.00		35.00
S6946	001	0		29	10	S6946_001_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	001	0		29	10	S6946_001_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	001	0		29	10	S6946_001_0	4			Preferred Brand	2	10	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	001	0		29	10	S6946_001_0	4			Non-Preferred Drug	2	10	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											79.00	34	34	34				63.00	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	001	0		29	10	S6946_001_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	002	0		29	10	S6946_002_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	002	0		29	10	S6946_002_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	002	0		29	10	S6946_002_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	002	0		29	10	S6946_002_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	37	37	37				63.00	37	37	37										37	37	37				37	37	37			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	002	0		29	10	S6946_002_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	003	0		29	10	S6946_003_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	003	0		29	10	S6946_003_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	003	0		29	10	S6946_003_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	003	0		29	10	S6946_003_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	39	39	39				63.00	39	39	39										39	39	39				39	39	39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	003	0		29	10	S6946_003_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	004	0		29	10	S6946_004_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	004	0		29	10	S6946_004_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	004	0		29	10	S6946_004_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	004	0		29	10	S6946_004_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	36	36	36				63.00	36	36	36										36	36	36				36	36	36			36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	004	0		29	10	S6946_004_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	005	0		29	10	S6946_005_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	005	0		29	10	S6946_005_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	005	0		29	10	S6946_005_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	005	0		29	10	S6946_005_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	005	0		29	10	S6946_005_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	006	0		29	10	S6946_006_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	006	0		29	10	S6946_006_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	006	0		29	10	S6946_006_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	006	0		29	10	S6946_006_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	006	0		29	10	S6946_006_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	007	0		29	10	S6946_007_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	007	0		29	10	S6946_007_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	007	0		29	10	S6946_007_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	007	0		29	10	S6946_007_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	007	0		29	10	S6946_007_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	008	0		29	10	S6946_008_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	008	0		29	10	S6946_008_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	008	0		29	10	S6946_008_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	008	0		29	10	S6946_008_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	008	0		29	10	S6946_008_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	009	0		29	10	S6946_009_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	009	0		29	10	S6946_009_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	009	0		29	10	S6946_009_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	009	0		29	10	S6946_009_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	009	0		29	10	S6946_009_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	010	0		29	10	S6946_010_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	010	0		29	10	S6946_010_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	010	0		29	10	S6946_010_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	010	0		29	10	S6946_010_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	32	32	32				63.00	32	32	32										32	32	32				32	32	32			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	010	0		29	10	S6946_010_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	011	0		29	10	S6946_011_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	011	0		29	10	S6946_011_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	011	0		29	10	S6946_011_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	011	0		29	10	S6946_011_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	33	33	33				63.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	011	0		29	10	S6946_011_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	012	0		29	10	S6946_012_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	012	0		29	10	S6946_012_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	012	0		29	10	S6946_012_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	012	0		29	10	S6946_012_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	33	33	33				63.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	012	0		29	10	S6946_012_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	013	0		29	10	S6946_013_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	013	0		29	10	S6946_013_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	013	0		29	10	S6946_013_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	013	0		29	10	S6946_013_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	31	31	31				63.00	31	31	31										31	31	31				31	31	31			31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	013	0		29	10	S6946_013_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	014	0		29	10	S6946_014_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	014	0		29	10	S6946_014_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	014	0		29	10	S6946_014_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	014	0		29	10	S6946_014_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											79.00	39	39	39				63.00	39	39	39										39	39	39				39	39	39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	014	0		29	10	S6946_014_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	015	0		29	10	S6946_015_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	015	0		29	10	S6946_015_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	015	0		29	10	S6946_015_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	015	0		29	10	S6946_015_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	32	32	32				63.00	32	32	32										32	32	32				32	32	32			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	015	0		29	10	S6946_015_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	016	0		29	10	S6946_016_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	016	0		29	10	S6946_016_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	016	0		29	10	S6946_016_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	016	0		29	10	S6946_016_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	33	33	33				63.00	33	33	33										33	33	33				33	33	33			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	016	0		29	10	S6946_016_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	017	0		29	10	S6946_017_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	017	0		29	10	S6946_017_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	017	0		29	10	S6946_017_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	017	0		29	10	S6946_017_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	39	39	39				63.00	39	39	39										39	39	39				39	39	39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	017	0		29	10	S6946_017_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	018	0		29	10	S6946_018_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	018	0		29	10	S6946_018_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	018	0		29	10	S6946_018_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	018	0		29	10	S6946_018_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	34	34	34				63.00	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	018	0		29	10	S6946_018_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	019	0		29	10	S6946_019_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	019	0		29	10	S6946_019_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	019	0		29	10	S6946_019_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	019	0		29	10	S6946_019_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	37	37	37				63.00	37	37	37										37	37	37				37	37	37			37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	019	0		29	10	S6946_019_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	020	0		29	10	S6946_020_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	020	0		29	10	S6946_020_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	020	0		29	10	S6946_020_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	020	0		29	10	S6946_020_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	34	34	34				63.00	34	34	34										34	34	34				34	34	34			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	020	0		29	10	S6946_020_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	021	0		29	10	S6946_021_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	021	0		29	10	S6946_021_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	021	0		29	10	S6946_021_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	021	0		29	10	S6946_021_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	021	0		29	10	S6946_021_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	022	0		29	10	S6946_022_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	022	0		29	10	S6946_022_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	022	0		29	10	S6946_022_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	022	0		29	10	S6946_022_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	40	40	40				63.00	40	40	40										40	40	40				40	40	40			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	022	0		29	10	S6946_022_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	023	0		29	10	S6946_023_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	023	0		29	10	S6946_023_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	023	0		29	10	S6946_023_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	023	0		29	10	S6946_023_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	023	0		29	10	S6946_023_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	024	0		29	10	S6946_024_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	024	0		29	10	S6946_024_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	024	0		29	10	S6946_024_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	024	0		29	10	S6946_024_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	024	0		29	10	S6946_024_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	025	0		29	10	S6946_025_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	025	0		29	10	S6946_025_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	025	0		29	10	S6946_025_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	025	0		29	10	S6946_025_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	025	0		29	10	S6946_025_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	026	0		29	10	S6946_026_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	026	0		29	10	S6946_026_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	026	0		29	10	S6946_026_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	026	0		29	10	S6946_026_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	39	39	39				63.00	39	39	39										39	39	39				39	39	39			39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	026	0		29	10	S6946_026_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	027	0		29	10	S6946_027_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	027	0		29	10	S6946_027_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	027	0		29	10	S6946_027_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	027	0		29	10	S6946_027_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	027	0		29	10	S6946_027_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	028	0		29	10	S6946_028_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	028	0		29	10	S6946_028_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	028	0		29	10	S6946_028_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	028	0		29	10	S6946_028_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	35	35	35				63.00	35	35	35										35	35	35				35	35	35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	028	0		29	10	S6946_028_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	029	0		29	10	S6946_029_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	029	0		29	10	S6946_029_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	029	0		29	10	S6946_029_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	029	0		29	10	S6946_029_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	029	0		29	10	S6946_029_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	059	0		29	10	S6946_059_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	059	0		29	10	S6946_059_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	059	0		29	10	S6946_059_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	059	0		29	10	S6946_059_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	059	0		29	10	S6946_059_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	060	0		29	10	S6946_060_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	060	0		29	10	S6946_060_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	060	0		29	10	S6946_060_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	060	0		29	10	S6946_060_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	060	0		29	10	S6946_060_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	061	0		29	10	S6946_061_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	061	0		29	10	S6946_061_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	061	0		29	10	S6946_061_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	061	0		29	10	S6946_061_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	061	0		29	10	S6946_061_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	062	0		29	10	S6946_062_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	18.00				1.00	2.00	3.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	062	0		29	10	S6946_062_0	4			Generic	2	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				8.00			0.27	0.10		0.27	0.10	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S6946	062	0		29	10	S6946_062_0	4			Preferred Brand	2	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00
S6946	062	0		29	10	S6946_062_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.00	38	38	38				63.00	38	38	38										38	38	38				38	38	38			38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00
S6946	062	0		29	10	S6946_062_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											617.00	25						617.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	001	0		29	10	S7126_001_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	001	0		29	10	S7126_001_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	001	0		29	10	S7126_001_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.10	19		19				31.19	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	001	0		29	10	S7126_001_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											82.42	42						52.41	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	001	0		29	10	S7126_001_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	002	0		29	10	S7126_002_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	002	0		29	10	S7126_002_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	002	0		29	10	S7126_002_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.26	19		19				32.66	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	002	0		29	10	S7126_002_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											89.26	41						58.15	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	002	0		29	10	S7126_002_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	003	0		29	10	S7126_003_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	003	0		29	10	S7126_003_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	003	0		29	10	S7126_003_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.61	19		19				36.54	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	003	0		29	10	S7126_003_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											87.47	43						56.61	41												43						41					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	003	0		29	10	S7126_003_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	004	0		29	10	S7126_004_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	004	0		29	10	S7126_004_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	004	0		29	10	S7126_004_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											34.70	19		19				36.18	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	004	0		29	10	S7126_004_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											82.95	43						58.81	41												43						41					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	004	0		29	10	S7126_004_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	005	0		29	10	S7126_005_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	005	0		29	10	S7126_005_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	005	0		29	10	S7126_005_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											36.01	17		17				30.46	15		15												15						15			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	005	0		29	10	S7126_005_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											69.35	41						58.90	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	005	0		29	10	S7126_005_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	006	0		29	10	S7126_006_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	006	0		29	10	S7126_006_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	006	0		29	10	S7126_006_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.01	20		20				34.37	18		18												18						18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	006	0		29	10	S7126_006_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											97.18	42						58.90	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	006	0		29	10	S7126_006_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	007	0		29	10	S7126_007_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	007	0		29	10	S7126_007_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	007	0		29	10	S7126_007_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											40.20	20		20				35.90	18		18												18						18			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	007	0		29	10	S7126_007_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											98.63	45						59.84	43												45						43					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	007	0		29	10	S7126_007_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	008	0		29	10	S7126_008_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	008	0		29	10	S7126_008_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	008	0		29	10	S7126_008_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											38.88	18		18				32.86	16		16												16						16			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	008	0		29	10	S7126_008_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											65.12	38						55.73	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	008	0		29	10	S7126_008_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	009	0		29	10	S7126_009_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	009	0		29	10	S7126_009_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	009	0		29	10	S7126_009_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.24	19		19				32.15	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	009	0		29	10	S7126_009_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											92.25	42						59.75	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	009	0		29	10	S7126_009_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	010	0		29	10	S7126_010_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	010	0		29	10	S7126_010_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	010	0		29	10	S7126_010_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											34.02	19		19				36.32	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	010	0		29	10	S7126_010_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											98.24	42						64.54	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	010	0		29	10	S7126_010_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	011	0		29	10	S7126_011_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	011	0		29	10	S7126_011_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	011	0		29	10	S7126_011_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.84	19		19				33.26	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	011	0		29	10	S7126_011_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											76.14	39						52.13	37												39						37					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	011	0		29	10	S7126_011_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	012	0		29	10	S7126_012_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	012	0		29	10	S7126_012_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	012	0		29	10	S7126_012_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.96	17		17				30.55	15		15												15						15			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	012	0		29	10	S7126_012_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											63.01	38						54.04	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	012	0		29	10	S7126_012_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	013	0		29	10	S7126_013_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	013	0		29	10	S7126_013_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	013	0		29	10	S7126_013_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											34.97	19		19				32.91	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	013	0		29	10	S7126_013_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											80.26	42						57.27	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	013	0		29	10	S7126_013_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	014	0		29	10	S7126_014_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	014	0		29	10	S7126_014_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	014	0		29	10	S7126_014_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											34.18	19		19				33.55	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	014	0		29	10	S7126_014_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											82.71	41						52.66	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	014	0		29	10	S7126_014_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	015	0		29	10	S7126_015_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	015	0		29	10	S7126_015_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	015	0		29	10	S7126_015_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.89	17		17				30.65	15		15												15						15			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	015	0		29	10	S7126_015_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											61.76	37						52.16	35												37						35					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	015	0		29	10	S7126_015_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	016	0		29	10	S7126_016_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	016	0		29	10	S7126_016_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	016	0		29	10	S7126_016_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.59	19		19				35.45	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	016	0		29	10	S7126_016_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											80.76	43						53.18	41												43						41					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	016	0		29	10	S7126_016_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	017	0		29	10	S7126_017_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	017	0		29	10	S7126_017_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	017	0		29	10	S7126_017_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.55	19		19				32.28	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	017	0		29	10	S7126_017_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											72.38	38						47.24	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	017	0		29	10	S7126_017_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	018	0		29	10	S7126_018_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	018	0		29	10	S7126_018_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	018	0		29	10	S7126_018_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											37.80	18		18				32.18	16		16												16						16			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	018	0		29	10	S7126_018_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											63.48	38						53.59	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	018	0		29	10	S7126_018_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	019	0		29	10	S7126_019_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	019	0		29	10	S7126_019_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	019	0		29	10	S7126_019_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											39.68	19		19				37.27	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	019	0		29	10	S7126_019_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											80.02	40						55.49	38												40						38					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	019	0		29	10	S7126_019_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	020	0		29	10	S7126_020_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	020	0		29	10	S7126_020_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	020	0		29	10	S7126_020_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.92	17		17				30.34	15		15												15						15			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	020	0		29	10	S7126_020_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											63.24	38						53.97	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	020	0		29	10	S7126_020_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	021	0		29	10	S7126_021_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	021	0		29	10	S7126_021_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	021	0		29	10	S7126_021_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.39	19		19				35.51	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	021	0		29	10	S7126_021_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											94.79	46						58.12	44												46						44					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	021	0		29	10	S7126_021_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	022	0		29	10	S7126_022_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	022	0		29	10	S7126_022_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	022	0		29	10	S7126_022_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.94	19		19				35.70	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	022	0		29	10	S7126_022_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											76.75	39						54.39	37												39						37					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	022	0		29	10	S7126_022_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	023	0		29	10	S7126_023_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	023	0		29	10	S7126_023_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	023	0		29	10	S7126_023_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											36.39	19		19				34.13	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	023	0		29	10	S7126_023_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											75.35	38						46.67	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	023	0		29	10	S7126_023_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	024	0		29	10	S7126_024_0	5			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	024	0		29	10	S7126_024_0	5			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	024	0		29	10	S7126_024_0	5			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.84	17		17				30.68	15		15												15						15			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	024	0		29	10	S7126_024_0	5			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											63.63	38						53.39	36												38						36					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	024	0		29	10	S7126_024_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	025	0		29	10	S7126_025_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	025	0		29	10	S7126_025_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	025	0		29	10	S7126_025_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											40.58	19		19				39.48	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	025	0		29	10	S7126_025_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											89.95	41						57.15	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	025	0		29	10	S7126_025_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	026	0		29	10	S7126_026_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	026	0		29	10	S7126_026_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	026	0		29	10	S7126_026_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											31.07	18		18				33.44	16		16												16						16			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	026	0		29	10	S7126_026_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											78.57	40						55.26	38												40						38					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	026	0		29	10	S7126_026_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	027	0		29	10	S7126_027_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	027	0		29	10	S7126_027_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	027	0		29	10	S7126_027_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											33.86	19		19				32.51	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	027	0		29	10	S7126_027_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											95.57	43						57.16	41												43						41					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	027	0		29	10	S7126_027_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	028	0		29	10	S7126_028_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	028	0		29	10	S7126_028_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	028	0		29	10	S7126_028_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											38.27	19		19				36.05	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	028	0		29	10	S7126_028_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											99.85	45						61.61	43												45						43					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	028	0		29	10	S7126_028_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	029	0		29	10	S7126_029_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	029	0		29	10	S7126_029_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	029	0		29	10	S7126_029_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											34.42	18		18				32.74	16		16												16						16			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	029	0		29	10	S7126_029_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											78.41	41						53.59	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	029	0		29	10	S7126_029_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	030	0		29	10	S7126_030_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								9.00		27.00					2.00		6.00													5.00						5.00				9.00				9.00			0.30	0.07				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	030	0		29	10	S7126_030_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	030	0		29	10	S7126_030_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.81	17		17				31.04	15		15												15						15			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	030	0		29	10	S7126_030_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											69.50	40						57.61	38												40						38					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	030	0		29	10	S7126_030_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	031	0		29	10	S7126_031_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	031	0		29	10	S7126_031_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	031	0		29	10	S7126_031_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											35.69	19		19				35.44	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	031	0		29	10	S7126_031_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											95.33	41						60.85	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	031	0		29	10	S7126_031_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	032	0		29	10	S7126_032_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	032	0		29	10	S7126_032_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	032	0		29	10	S7126_032_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											40.26	19		19				39.00	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	032	0		29	10	S7126_032_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											91.13	42						59.12	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	032	0		29	10	S7126_032_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	033	0		29	10	S7126_033_0	2			Preferred Generic	2	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	033	0		29	10	S7126_033_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								12.00		36.00					5.00		15.00													12.50						12.50				12.00				12.00			0.40	0.17				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	033	0		29	10	S7126_033_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											37.96	19		19				37.21	17		17												17						17			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	033	0		29	10	S7126_033_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30								30			30		31											84.97	41						55.48	39												41						39					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	033	0		29	10	S7126_033_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	071	0		29	10	S7126_071_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	071	0		29	10	S7126_071_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	071	0		29	10	S7126_071_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	071	0		29	10	S7126_071_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											97.12	50						69.30	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	071	0		29	10	S7126_071_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	072	0		29	10	S7126_072_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	072	0		29	10	S7126_072_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	072	0		29	10	S7126_072_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	072	0		29	10	S7126_072_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.54	49						65.88	48												49						48					49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	072	0		29	10	S7126_072_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	073	0		29	10	S7126_073_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	073	0		29	10	S7126_073_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	073	0		29	10	S7126_073_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	073	0		29	10	S7126_073_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.64	43						66.25	42												43						42					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	073	0		29	10	S7126_073_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	074	0		29	10	S7126_074_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	074	0		29	10	S7126_074_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	074	0		29	10	S7126_074_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	074	0		29	10	S7126_074_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.59	50						73.99	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	074	0		29	10	S7126_074_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	075	0		29	10	S7126_075_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	075	0		29	10	S7126_075_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	075	0		29	10	S7126_075_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	075	0		29	10	S7126_075_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.81	37						48.97	36												37						36					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	075	0		29	10	S7126_075_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	076	0		29	10	S7126_076_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	076	0		29	10	S7126_076_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	076	0		29	10	S7126_076_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	076	0		29	10	S7126_076_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.29	43						57.56	42												43						42					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	076	0		29	10	S7126_076_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	077	0		29	10	S7126_077_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	077	0		29	10	S7126_077_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	077	0		29	10	S7126_077_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	077	0		29	10	S7126_077_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.55	48						59.46	46												48						46					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	077	0		29	10	S7126_077_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	078	0		29	10	S7126_078_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	078	0		29	10	S7126_078_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	078	0		29	10	S7126_078_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	078	0		29	10	S7126_078_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.82	42						62.53	40												42						40					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	078	0		29	10	S7126_078_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	079	0		29	10	S7126_079_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	079	0		29	10	S7126_079_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	079	0		29	10	S7126_079_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	079	0		29	10	S7126_079_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											94.08	50						66.97	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	079	0		29	10	S7126_079_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	080	0		29	10	S7126_080_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	080	0		29	10	S7126_080_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	080	0		29	10	S7126_080_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	080	0		29	10	S7126_080_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.81	47						65.46	45												47						45					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	080	0		29	10	S7126_080_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	081	0		29	10	S7126_081_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	081	0		29	10	S7126_081_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	081	0		29	10	S7126_081_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	081	0		29	10	S7126_081_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											92.94	50						64.78	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	081	0		29	10	S7126_081_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	082	0		29	10	S7126_082_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	082	0		29	10	S7126_082_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	082	0		29	10	S7126_082_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	082	0		29	10	S7126_082_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											88.07	50						65.67	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	082	0		29	10	S7126_082_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	083	0		29	10	S7126_083_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	083	0		29	10	S7126_083_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	083	0		29	10	S7126_083_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	083	0		29	10	S7126_083_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.78	44						64.28	42												44						42					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	083	0		29	10	S7126_083_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	084	0		29	10	S7126_084_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	084	0		29	10	S7126_084_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	084	0		29	10	S7126_084_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	084	0		29	10	S7126_084_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											87.30	50						62.94	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	084	0		29	10	S7126_084_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	085	0		29	10	S7126_085_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	085	0		29	10	S7126_085_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	085	0		29	10	S7126_085_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	085	0		29	10	S7126_085_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											94.19	50						64.35	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	085	0		29	10	S7126_085_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	086	0		29	10	S7126_086_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	086	0		29	10	S7126_086_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	086	0		29	10	S7126_086_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	086	0		29	10	S7126_086_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.98	47						67.90	46												47						46					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	086	0		29	10	S7126_086_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	087	0		29	10	S7126_087_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	087	0		29	10	S7126_087_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	087	0		29	10	S7126_087_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	087	0		29	10	S7126_087_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											94.84	50						64.75	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	087	0		29	10	S7126_087_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	088	0		29	10	S7126_088_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	088	0		29	10	S7126_088_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	088	0		29	10	S7126_088_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	088	0		29	10	S7126_088_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.45	43						57.56	42												43						42					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	088	0		29	10	S7126_088_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	089	0		29	10	S7126_089_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	089	0		29	10	S7126_089_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	089	0		29	10	S7126_089_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	089	0		29	10	S7126_089_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.21	49						58.78	48												49						48					49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	089	0		29	10	S7126_089_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	090	0		29	10	S7126_090_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	090	0		29	10	S7126_090_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	090	0		29	10	S7126_090_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	090	0		29	10	S7126_090_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.67	48						63.34	47												48						47					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	090	0		29	10	S7126_090_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	091	0		29	10	S7126_091_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	091	0		29	10	S7126_091_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	091	0		29	10	S7126_091_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	091	0		29	10	S7126_091_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.18	45						56.38	44												45						44					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	091	0		29	10	S7126_091_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	092	0		29	10	S7126_092_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	092	0		29	10	S7126_092_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	092	0		29	10	S7126_092_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	092	0		29	10	S7126_092_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											96.68	50						60.42	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	092	0		29	10	S7126_092_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	093	0		29	10	S7126_093_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	093	0		29	10	S7126_093_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	093	0		29	10	S7126_093_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	093	0		29	10	S7126_093_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.67	48						60.91	46												48						46					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	093	0		29	10	S7126_093_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	094	0		29	10	S7126_094_0	5			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	094	0		29	10	S7126_094_0	5			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	094	0		29	10	S7126_094_0	5			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	094	0		29	10	S7126_094_0	5			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											97.92	47						64.71	46												47						46					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	094	0		29	10	S7126_094_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	095	0		29	10	S7126_095_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	095	0		29	10	S7126_095_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	095	0		29	10	S7126_095_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	095	0		29	10	S7126_095_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.83	43						53.20	41												43						41					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	095	0		29	10	S7126_095_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	096	0		29	10	S7126_096_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	096	0		29	10	S7126_096_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	096	0		29	10	S7126_096_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	096	0		29	10	S7126_096_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.92	45						70.24	43												45						43					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	096	0		29	10	S7126_096_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	097	0		29	10	S7126_097_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	097	0		29	10	S7126_097_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	097	0		29	10	S7126_097_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	097	0		29	10	S7126_097_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.74	48						65.90	47												48						47					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	097	0		29	10	S7126_097_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	098	0		29	10	S7126_098_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	098	0		29	10	S7126_098_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	098	0		29	10	S7126_098_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	098	0		29	10	S7126_098_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.34	37						63.58	36												37						36					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	098	0		29	10	S7126_098_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	099	0		29	10	S7126_099_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	099	0		29	10	S7126_099_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	099	0		29	10	S7126_099_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	099	0		29	10	S7126_099_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											92.88	50						58.02	49												50						49					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	099	0		29	10	S7126_099_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	100	0		29	10	S7126_100_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	100	0		29	10	S7126_100_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	100	0		29	10	S7126_100_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	100	0		29	10	S7126_100_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											98.06	49						61.09	48												49						48					49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	100	0		29	10	S7126_100_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	101	0		29	10	S7126_101_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	101	0		29	10	S7126_101_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	101	0		29	10	S7126_101_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	101	0		29	10	S7126_101_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.11	47						72.10	45												47						45					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	101	0		29	10	S7126_101_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	102	0		29	10	S7126_102_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	102	0		29	10	S7126_102_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	102	0		29	10	S7126_102_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	102	0		29	10	S7126_102_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											99.06	43						63.72	42												43						42					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	102	0		29	10	S7126_102_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	103	0		29	10	S7126_103_0	3			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								8.00		24.00					1.00		3.00													2.50						2.50				8.00				8.00			0.27	0.03				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	103	0		29	10	S7126_103_0	3			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								17.00		51.00					10.00		30.00													25.00						25.00				17.00				17.00			0.57	0.33				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	103	0		29	10	S7126_103_0	3			Preferred Brand	4	11	1	2	3	1		110	01		100	1				30		90	1	2						90	30		31								47.00		141.00					47.00		141.00													117.50						117.50				47.00				47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	103	0		29	10	S7126_103_0	3			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											97.76	40						60.32	39												40						39					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	103	0		29	10	S7126_103_0	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												28							28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	104	0		29	10	S7126_104_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	104	0		29	10	S7126_104_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	104	0		29	10	S7126_104_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											57.14	22		22				57.14	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	104	0		29	10	S7126_104_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											94.62	50						58.11	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	104	0		29	10	S7126_104_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	105	0		29	10	S7126_105_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	105	0		29	10	S7126_105_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	105	0		29	10	S7126_105_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											56.69	22		22				56.60	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	105	0		29	10	S7126_105_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											96.19	50						59.07	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	105	0		29	10	S7126_105_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	106	0		29	10	S7126_106_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	106	0		29	10	S7126_106_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	106	0		29	10	S7126_106_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.09	22		22				57.13	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	106	0		29	10	S7126_106_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.13	50						56.27	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	106	0		29	10	S7126_106_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	107	0		29	10	S7126_107_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	107	0		29	10	S7126_107_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	107	0		29	10	S7126_107_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											58.73	22		22				57.06	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	107	0		29	10	S7126_107_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											92.59	50						57.79	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	107	0		29	10	S7126_107_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	108	0		29	10	S7126_108_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	108	0		29	10	S7126_108_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	108	0		29	10	S7126_108_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.71	22		22				57.17	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	108	0		29	10	S7126_108_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											84.73	50						56.14	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	108	0		29	10	S7126_108_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	109	0		29	10	S7126_109_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	109	0		29	10	S7126_109_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	109	0		29	10	S7126_109_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.49	22		22				57.21	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	109	0		29	10	S7126_109_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.81	50						56.63	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	109	0		29	10	S7126_109_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	110	0		29	10	S7126_110_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	110	0		29	10	S7126_110_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	110	0		29	10	S7126_110_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.40	22		22				57.08	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	110	0		29	10	S7126_110_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											84.04	50						56.09	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	110	0		29	10	S7126_110_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	111	0		29	10	S7126_111_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	111	0		29	10	S7126_111_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	111	0		29	10	S7126_111_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.93	22		22				57.00	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	111	0		29	10	S7126_111_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											85.87	50						56.23	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	111	0		29	10	S7126_111_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	112	0		29	10	S7126_112_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	112	0		29	10	S7126_112_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	112	0		29	10	S7126_112_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.98	22		22				56.26	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	112	0		29	10	S7126_112_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											82.63	50						54.69	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	112	0		29	10	S7126_112_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	113	0		29	10	S7126_113_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	113	0		29	10	S7126_113_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	113	0		29	10	S7126_113_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.89	22		22				56.85	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	113	0		29	10	S7126_113_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.68	50						56.18	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	113	0		29	10	S7126_113_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	114	0		29	10	S7126_114_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	114	0		29	10	S7126_114_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	114	0		29	10	S7126_114_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.00	22		22				55.34	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	114	0		29	10	S7126_114_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											84.38	50						55.05	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	114	0		29	10	S7126_114_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	115	0		29	10	S7126_115_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	115	0		29	10	S7126_115_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	115	0		29	10	S7126_115_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.30	22		22				56.49	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	115	0		29	10	S7126_115_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.42	50						56.00	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	115	0		29	10	S7126_115_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	116	0		29	10	S7126_116_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	116	0		29	10	S7126_116_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	116	0		29	10	S7126_116_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.37	22		22				56.95	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	116	0		29	10	S7126_116_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											83.99	50						55.87	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	116	0		29	10	S7126_116_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	117	0		29	10	S7126_117_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	117	0		29	10	S7126_117_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	117	0		29	10	S7126_117_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											59.79	22		22				56.05	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	117	0		29	10	S7126_117_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											85.78	50						55.36	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	117	0		29	10	S7126_117_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	118	0		29	10	S7126_118_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	118	0		29	10	S7126_118_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	118	0		29	10	S7126_118_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											62.51	22		22				55.94	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	118	0		29	10	S7126_118_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											77.79	50						53.41	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	118	0		29	10	S7126_118_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	119	0		29	10	S7126_119_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	119	0		29	10	S7126_119_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	119	0		29	10	S7126_119_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.28	22		22				56.35	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	119	0		29	10	S7126_119_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											85.60	50						56.11	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	119	0		29	10	S7126_119_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	120	0		29	10	S7126_120_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	120	0		29	10	S7126_120_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	120	0		29	10	S7126_120_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.33	22		22				55.75	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	120	0		29	10	S7126_120_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											84.22	50						54.51	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	120	0		29	10	S7126_120_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	121	0		29	10	S7126_121_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	121	0		29	10	S7126_121_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	121	0		29	10	S7126_121_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.56	22		22				55.82	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	121	0		29	10	S7126_121_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											83.01	50						54.72	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	121	0		29	10	S7126_121_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	122	0		29	10	S7126_122_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	122	0		29	10	S7126_122_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	122	0		29	10	S7126_122_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.52	22		22				55.21	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	122	0		29	10	S7126_122_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											79.54	50						54.10	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	122	0		29	10	S7126_122_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	123	0		29	10	S7126_123_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	123	0		29	10	S7126_123_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	123	0		29	10	S7126_123_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											58.58	22		22				55.42	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	123	0		29	10	S7126_123_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											87.58	50						54.70	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	123	0		29	10	S7126_123_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	124	0		29	10	S7126_124_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	124	0		29	10	S7126_124_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	124	0		29	10	S7126_124_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.84	22		22				56.74	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	124	0		29	10	S7126_124_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											83.83	50						55.83	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	124	0		29	10	S7126_124_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	125	0		29	10	S7126_125_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	125	0		29	10	S7126_125_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	125	0		29	10	S7126_125_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.65	22		22				54.49	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	125	0		29	10	S7126_125_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											77.59	48						53.24	46												48						46					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	125	0		29	10	S7126_125_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	126	0		29	10	S7126_126_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	126	0		29	10	S7126_126_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	126	0		29	10	S7126_126_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.20	22		22				55.44	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	126	0		29	10	S7126_126_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											81.52	50						54.22	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	126	0		29	10	S7126_126_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	127	0		29	10	S7126_127_0	4			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	127	0		29	10	S7126_127_0	4			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	127	0		29	10	S7126_127_0	4			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											62.04	22		22				55.75	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	127	0		29	10	S7126_127_0	4			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											80.37	50						54.95	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	127	0		29	10	S7126_127_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	128	0		29	10	S7126_128_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	128	0		29	10	S7126_128_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	128	0		29	10	S7126_128_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.94	22		22				56.57	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	128	0		29	10	S7126_128_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.93	50						57.20	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	128	0		29	10	S7126_128_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	129	0		29	10	S7126_129_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	129	0		29	10	S7126_129_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	129	0		29	10	S7126_129_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.40	22		22				56.56	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	129	0		29	10	S7126_129_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.45	50						57.22	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	129	0		29	10	S7126_129_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	130	0		29	10	S7126_130_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	130	0		29	10	S7126_130_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	130	0		29	10	S7126_130_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											61.77	22		22				57.22	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	130	0		29	10	S7126_130_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											85.82	50						56.33	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	130	0		29	10	S7126_130_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	131	0		29	10	S7126_131_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	131	0		29	10	S7126_131_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	131	0		29	10	S7126_131_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.11	22		22				57.64	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	131	0		29	10	S7126_131_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											87.84	50						55.92	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	131	0		29	10	S7126_131_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	132	0		29	10	S7126_132_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	132	0		29	10	S7126_132_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	132	0		29	10	S7126_132_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											62.78	22		22				56.76	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	132	0		29	10	S7126_132_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											83.46	50						56.33	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	132	0		29	10	S7126_132_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	133	0		29	10	S7126_133_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	133	0		29	10	S7126_133_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	133	0		29	10	S7126_133_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											62.72	22		22				55.92	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	133	0		29	10	S7126_133_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											77.98	50						54.08	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	133	0		29	10	S7126_133_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	134	0		29	10	S7126_134_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	134	0		29	10	S7126_134_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	134	0		29	10	S7126_134_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											58.57	22		22				57.49	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	134	0		29	10	S7126_134_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											91.34	50						58.08	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	134	0		29	10	S7126_134_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	135	0		29	10	S7126_135_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	135	0		29	10	S7126_135_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	135	0		29	10	S7126_135_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											63.22	22		22				58.93	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	135	0		29	10	S7126_135_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											86.80	50						57.27	48												50						48					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	135	0		29	10	S7126_135_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	136	0		29	10	S7126_136_0	2			Preferred Generic	4	11	1	2	1	1		110	01		100	1				30		90	1	2						90	30		31								15.00		45.00					0.00		0.00													0.00						0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	136	0		29	10	S7126_136_0	2			Generic	4	01	1	2	2	1		110	01		100	1				30		90	1	2						90	30		31								20.00		60.00					15.00		45.00													37.50						37.50				20.00				20.00			0.67	0.50				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
S7126	136	0		29	10	S7126_136_0	2			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	1	2						90	30		31											60.09	22		22				55.91	20		20												20						20			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00
S7126	136	0		29	10	S7126_136_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											83.22	47						54.21	45												47						45					47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier													35.00			35.00			35.00			35.00			35.00		35.00
S7126	136	0		29	10	S7126_136_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																											
